62 year old man trying to harm himself. Wife finds him confused. calls ambulance.

Pills on the ground, alcohol

BP 80/0 HR 130 sinus tachy

Mental status declines on way to hospital

Intubated for airway protection

Sushama SaijwaniBoston Medical Center

Emergency Medicine Residency

Depression, Anxiety, Migraine, Pain

More deaths than any other medicine overdose

60% overdose intentional

Half life 36h up to 72 h in overdose

Blood level ranges in overdose Most in tissue NOT blood (1-2%) Dialysis does not work Peaks 2-6 hours after ingestion Most people die early if they

have taken fatal dose

Amitriptyline – 40% Imipramine –17% Doxepin – 14% Nortriptyline—12%

Nonspecific = TCA affect many receptors

1. Anti Histamine sleepy, coma

2. Anti muscarinic = inhibits Acetylcholine

Neuro: confusion, delirium, ataxia, slurred speech, dilated pupils

Tachycardic, Hyperthermic, dry mouth

3) Inhibits norepinephrine/serotonin reuptake

NE dysrhythmias

Serotonin Serotonin Syndrome

4) Blocks Na channel influx: CARDIOTOXIC

Decreased contractilityVentricular dysrhythmias ( reentry loops)Heart BlockWide PR, Wide QRS, Prolonged QTRight Axis Deviation terminal QRS =

positive R wave in avR negative S wave in I

5) Blocks Potassium Channels in myocardium

Long QTc Torsades de Pointes

6) GABA A receptor Antagonist

Seizures

Change in Mental Status

Dry mouth, axilla, urinary retention

Sinus tachy, conduction delay, ectopy

Hypotension Respiratory

depression

Find out what drug and how much

EKG!! Must monitor

Glucose Lytes Renal function TCA tox screen +/- ABG

IV, O2, Monitor

Change in MS/respiratory distress intubate!

Activated Charcoal for everyone 1g/kg, decreases absorption from stomach

+/- Gastric Lavage if early

Benzodiazepine: IV lorazepam/diazepam If that does not work Phenobarbital

Phenytoin does NOT work

All change in mental status Thiamine & Naloxone

First try NS fluid

If that does not work Sodium bicarbonate

If that does not work Norepinephrine

Dopamine does not work!

Because of Sodium channel block in heart

Sodium bicarbonateIncreases sodium in bloodAlkalinize bloodGive when QRS > 100 ms, ventricular

arrhythmia, Right axis in aVRBolus 1-2 meq/kgpH 7.50 to 7.55 OR3 amps ( 50 meq) in 1L D5WMonitor Na, K, pH

If Sodium bicarbonate does not work try lidocaine

No beta blocker or calcium channel blocker

Unstable from dysrhythmia Cardioversion

Tosades de Pointes: 2G MagnesiumMake sure no other cause of Torsades

Psychiatric evaluation

If patient asymptomatic discharge after 6 hours

If patient symptomatic admit for observation

Discharge when pt has not had symptoms for 24 hours