Vancouver IM LMR

In today’s noon report we covered the case of a 67 year old man who presented acutely with GCS of 6. He was notably on amitriptyline at home and was treated as TCA overdose. After waking up he admitted to taking 1.25g of amitriptyline in a suicide attempt.

Didactic slides can be found here.

Key takeaways:

• Approach to toxicology:
  • History: collateral, collateral, collateral!
  • Physical: look for toxidromes. Assess vitals, respiratory rate, GCS, temperature, skin (dry vs diaphoretic?), tremor, rigidity/ reflexes, and ankle clonus.
  • Everyone should get:
    • Fingerstick glucose!!
    • CBC, lytes, creatinine, CK, Mg/ Ca/ phos, LFTs
    • Calculate AG and OG (get serum osmolality)
    • ABG/ VBG, lactate
    • Serum tox panel
    • Urinalysis +/- urine drug screen
    • B-HCG if reproductive age woman
    • 12-lead ECG
  • Management:
    • ABC-MOVIE
    • CALL POISON CONTROL
    • Decontamination
    • Elimination
    • Antidote
    • Supportive care and monitoring
    • Disposition
• TCA overdose:
  • Main effects are:
    • Cardiovascular (tachycardia, hypotension, wide QRS and VT/VF)
    • CNS (delirium, agitation, sedation, coma, seizures)
    • Anticholinergic toxidrome (hyperthermia, dry and flushed skin, dilated pupils, urinary retention, delirium and coma)
  • Diagnosis:
    • ECG is key! Expect to see wide QRS and terminal rightward axis deviation (deep slurred S wave in I and tall slurred R wave in aVR)
      • QRS > 100ms = increased risk of seizures
      • QRS > 160ms = increased risk of VT/VF
  • Management:
    • Decontamination: activated charcoal if within 1-2h of ingestion
    • Elimination: none
    • Antidote: none
      • However, sodium bicarbonate is the mainstay of treatment for wide QRS and arrhythmias