What James Bond got right – and wrong – about digitalis toxicity

In 2006’s Casino Royale, Bond – James Bond – has something slipped into his martini during a high-stakes poker tournament with resident bad guy, Le Chiffre. He takes a sip and the world begins to blur: delirious, he rushes to the bathroom with a salt shaker and attempts to vomit; unsuccessful, he goes to his car and calls MI6, who tell him he’s been poisoned with digitalis – and is going into cardiac arrest.

Bond, heart pounding, places a defibrillator on his chest and injects himself in the neck with lidocaine. Just as his heart is about to stop he presses the button on the defibrillator, but to no avail: the wires aren’t connected. He passes out. If not for Vesper Lynd rushing to the scene and shocking him back to life, the movie might have ended right there.

As manufacturers of the only antidote for digitalis toxicity, we recall this scene with interest, asking: Is this an accurate portrayal of its effects? Its treatment?

Digitalis toxicity, explained

In Casino Royale, digitalis toxicity (or overdose) is part of Le Chiffre’s evil plan. But in a medical context, such toxicity typically occurs in patients undergoing digitalis therapy for congestive heart failure and/or irregular heartbeats such as atrial fibrillation. Digitalis toxicity typically results in patients being hospitalized; in some cases, it can even be fatal.

Broadly speaking, digitalis strengthens the heart’s ability to contract blood, increasing blood flow throughout the body. So it makes sense that, in large doses, you might experience – as Bond does – a pounding feeling in the chest (i.e., dysrhythmias), as well as dizziness, nausea, and confusion.

Yet while the film may have gotten the symptoms of digitalis toxicity right, the timing was off: digitalis toxicity typically takes at least six hours to show its effects in the acute setting. Chronic toxicity can be more insidious and harder to diagnose.

Of course, Bond films rely on sensationalized drama. This might also explain his use of a defibrillator, a treatment physicians say might trigger even worse heart dysrythmias – or stop the heartbeat altogether. The medication he injected would have likely sufficed, although lidocaine itself can also contribute to dysrhythmias if not dosed properly.

These may not be important distinctions in a Hollywood action movie, but the differences are critical for patients in the real world suffering with digoxin toxicity. That’s because digitalis toxicity can be difficult to recognize in an already ill patient, and early detection and treatment can result in improved outcomes.

More typical cases of digoxin toxicity may not be the stuff of hollywood film scripts, but they can still be potentially life-threatening. Early recognition of potentially life-threatening digoxin toxicity can be life-saving, so it’s important that physicians recognize the signs. Our clinically-proven antidote plays an important role in treating digitalis toxicity – even if it would make that moment in Casino Royale a bit less exciting…