Case presentation
A 41-year-old woman was presented to the local emergency department
(ED), in Torbat-e Heydariyeh, via Emergency Medical Services with
altered mental status, following a suicide attempt with Tricyclic
Antidepressant. Her prehospital vital signs included: a temperature of
37 °C, a pulse rate of 86/minute, respiratory rate of 16/minute, and
blood pressure of 110/70 mm Hg. The patient was unconscious, drowsy, and
assessed with a Glasgow Coma Scale (GCS) of 13 out of 15. Gastric lavage
was promptly performed and then she was transferred to the referral
center for further evaluation.
She was admitted to the inpatient poisoning care of
Emam Reza hospital of Mashhad,
the next morning. Upon arrival,
the patient was non-vocal and unresponsive to the pain. The GCS was
estimated at 9-10/15. vital signs
and other physical examinations showed acceptable general condition.
Normal breath sounds with no rales or murmur were observed. Her medical
history was significant for diabetes, ischemic heart disease, and
depression. Medications available to the patient included
Nortriptyline, Metformin,
Livergol, Gabapentin, and Thiamine supplement.
She had taken metformin for
treatment of her diabetes for years. Upon questioning, it was claimed
that she had taken large but uncertain quantities of
Nortriptyline,
Livergol,
Gabapentin, and Thiamine, about
50 pills in total. Social history
was positive for waterpipe tobacco smoking.
Due to the patient history mentioned above, we ran a full blood and
urine analysis which was positive for TCAs. An ECG on presentation
demonstrated a
QTc interval of 481 milliseconds
at 10 AM (Figure 1). The patient
was treated with a vial of bicarbonate and 10 ccs of potassium chloride,
intravenous (I.V). the subsequent ECG, at 4 PM, demonstrated
QTc shortening to 463
milliseconds (Figure 2). Blood
glucose control was managed according to the insulin therapy protocol.
ECG, Arterial blood gases (ABG), and urinary output were regularly
checked. During this time, she remained hemodynamically stable, and
no other abnormality was noted on
the serial ECG. She also received
I.V pantoprazole (40 mg), and
serum therapy had been ongoing since her early admission. A psychiatry
consult was ordered to assess suicidal ideation in the context of TCA
overdose.
on the evening of the same day, the patient wished for her discharge
against the medical advice. The possible risks of an
early self-discharge against the
medical advice, including; cardiac arrhythmia and heart arrest were
explained to her. Even with this explanation, the patient remained
intensified with her decision and immediately started the process and
got discharged at 5 PM. But on a further phone call follow-up in the
next month, the patient was fine with no complications and reported full
remission of all symptoms.