A 27 years old man,previously healthy ,brought by his brother to ED unresponsive ,He was seen last normal last night . No other information is available . On examination , his Vital signs : HR: 130 ,BP: 88/ 50 ,RR: 30 breath per min ,SpO2: 80% % in 100% oxygen, T:39.6 C, blood sugar : 7 mmol/l . He had shallow rapid breathing with b/l equal air entry . His GCS: 8/15 V2 M2 E4, with pupils 3 mm b/l sluggish reaction, rest of exam unremarkable.
ECG is below
Q1 How will you approach this patient and what is your DD ?
Q2 What you will give him ? ( provide a list)
I remember this patient very distinctly. Thanks for sharing Dr Suad
added comments on TCA
If QRS > 110 = predictive of neurotoxicity
If QRS > 160 = predictive of cardiac toxicity
In cases of ventricular arrhythmias, my preferred approach is synchronised cardioversion. And as mentioned, first line anti arrhythmic is Lidocaine.
Indications to give sodium bicarb push doses in TCA (not limited to): QRS>100
When treating a patient with TCA with NaHCO3 make sure to watch the serum sodium and ph closely. If you have given 3-4 amps with no resolution of QRS, then re-consider your diagnosis. DO NOT OVER PUSH NaHCO3- without monitoring the serum Na and pH
If the pH=7.55, you cannot give any more sodium bicarb, and so the next drug of choice is hypertonic saline 3%
In cases of refractory seizures or refractory ventricular arrhythmias, call the poison center ASAP and prepare intralipid. (Do not wait until the patient arrests). Be mindful of the severity of the overdose.
Great blog! Thanks