A 22-year-old female presents to the ED with an overdose.
She has a history of depression, and there were
empty bottles found at her bedside. The bottles had contained
clonazepam (a benzodiazepine) and nortriptyline
(a tricyclic). The patient is unconscious with diminished
breathing and is unable to protect her own airway.
The BEST next step is to:
A) Intubate the patient.
B) Begin gastric lavage and administer charcoal.
C) Administer flumazenil, a benzodiazepine antagonist,
to awaken her and improve her respirations.
D) Administer bicarbonate.
E) None of the above.
Discussion
The correct answer is A. This patient should be intubated.
Remember that in any emergency situation that
the ABCs (airway, breathing, and circulation) are the
priority. Answer B is incorrect because, as noted above,
patients who are lavaged have a higher incidence of
pulmonary aspiration—an even greater concern in the
obtunded patient. In fact, airway protection is mandatory
before undertaking lavage. Answer C is incorrect.
Flumazenil will reverse the benzodiazepine. However,
we know from experience that seizures in patients who
have had flumazenil are particularly difficult to control.
This would be particularly problematic in a patient
with a mixed overdose, such as with a tricyclic, where
seizures are common. Thus, it is recommended that
flumazenil be used only as a reversal agent after procedural
sedation in patients who are not on chronic
benzodiazepines.
* *
You notice that the patient begins to have an abnormal
ECG tracing.
Which of the following findings would you expect
to find in a tricyclic overdose?
A) Normal QRS complex.
B) 2nd- and 3rd-degree heart block.
C) Widened QRS complex.
D) Sinus tachycardia.
E) All of the above.
Discussion
The correct answer is E. All of the above findings can be
seen with a tricyclic overdose. In fact, the most common
presenting rhythm is a narrow-complex sinus tachycardia.
As toxicity progresses, you can get a prolonged PR
interval, a widened QRS complex and a prolonged QT
interval. Heart blocks (2nd- and 3rd-degree) herald a
poor outcome and may be seen late in the course. Asystole
is not a primary rhythm in tricyclic overdose and
tends to reflect the end-stage of another arrhythmia.
She has a history of depression, and there were
empty bottles found at her bedside. The bottles had contained
clonazepam (a benzodiazepine) and nortriptyline
(a tricyclic). The patient is unconscious with diminished
breathing and is unable to protect her own airway.
The BEST next step is to:
A) Intubate the patient.
B) Begin gastric lavage and administer charcoal.
C) Administer flumazenil, a benzodiazepine antagonist,
to awaken her and improve her respirations.
D) Administer bicarbonate.
E) None of the above.
Discussion
The correct answer is A. This patient should be intubated.
Remember that in any emergency situation that
the ABCs (airway, breathing, and circulation) are the
priority. Answer B is incorrect because, as noted above,
patients who are lavaged have a higher incidence of
pulmonary aspiration—an even greater concern in the
obtunded patient. In fact, airway protection is mandatory
before undertaking lavage. Answer C is incorrect.
Flumazenil will reverse the benzodiazepine. However,
we know from experience that seizures in patients who
have had flumazenil are particularly difficult to control.
This would be particularly problematic in a patient
with a mixed overdose, such as with a tricyclic, where
seizures are common. Thus, it is recommended that
flumazenil be used only as a reversal agent after procedural
sedation in patients who are not on chronic
benzodiazepines.
* *
You notice that the patient begins to have an abnormal
ECG tracing.
Which of the following findings would you expect
to find in a tricyclic overdose?
A) Normal QRS complex.
B) 2nd- and 3rd-degree heart block.
C) Widened QRS complex.
D) Sinus tachycardia.
E) All of the above.
Discussion
The correct answer is E. All of the above findings can be
seen with a tricyclic overdose. In fact, the most common
presenting rhythm is a narrow-complex sinus tachycardia.
As toxicity progresses, you can get a prolonged PR
interval, a widened QRS complex and a prolonged QT
interval. Heart blocks (2nd- and 3rd-degree) herald a
poor outcome and may be seen late in the course. Asystole
is not a primary rhythm in tricyclic overdose and
tends to reflect the end-stage of another arrhythmia.
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