by Daniel Petrosky M.D.
HPI
- 31 y.o. female presents with acute change in mental status
- Family found unresponsive
- EMS trialed one dose of naloxone without effect
PMHX
- Multiple sclerosis, chronic pain, opioid use disorder, generalized anxiety disorder, and major depressive disorder,
Physical Exam
- Markedly dry mucous membranes and cracked, dry lips
- Pt lethargic, localizes pain, mumbles, and does not follow commands
- Afebrile
Work-up
- ECG shows prolonged QT otherwise unremarkable
- BMP, CBC, LFTs, acetaminophen, salicylate , UA all WNL
- UDS positive for TCH, benzos, and amphetamines
- Bladder scan and subsequent bladder catheterization reveal over 1 L clear urine
Case Conclusion
- Several hours later the pt was able to state that she overdosed on her amitriptyline and wrote a suicide note
- Toxicology consulted did not recommend any acute interventions
- Psychiatry consulted for suicide attempt.
TCA Overdose Pearls
- Toxicity can vary in presentation and thorough review of medications as well as collateral from family can be very important
- TCA overdose can be tricky as it can affect multiple organ systems and present with anti-cholinergic properties (see below), ECG changes such as QTc prolongation, QRS prolongation, and a “terminal r wave” in lead aVR , and seizures.
- Symptoms typically occur 6 hours after ingestion and can be worse with con-ingestion of sedatives
- Those with ECG changes should be monitored for 36-48 hrs
- Treatment is aimed at overcoming cardiac sodium channel blockade with sodium bicarbonate or hypertonic saline, and is reserved for those patients with ECG changes
| Classic Symptom Description | Physical Exam Manifestation |
| “Mad as a Hatter” | Acute encephalopathy |
| “Red as a Beet” | Erythroderma (in fair skinned patients) |
| “Blind as a Bat” | Dilated and unresponsive pupils |
| “Dry as a Bone” | Dry, cracked mucous membranes, no sweating |
| “Tachy as a Leisure Suit” | Sinus tachycardia |
| “Hot as Hell” | Hyperthermia |
References:
In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw Hill; 2016, 1194-1199.
