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.