Case PresentationCase Presentation

Ib t is a m A l H o q a n i

– 1E M R

Outline:Outline: Case Management Pitfalls Topic talk Take home message

:T h e C a s e :T h e C a s e

Initial managementInitial management

Primary Survey:A …B …C …D …

Brif History Secondary

Survey

Adjusts:ECG:

, s in u s t a c h y c a r d ia , n o p r o lo n g Q T f la t T w a v e a ll

o v e r

RBS: 6ABG:

=7 .3 7 , p H3 =2 1 , H C O

2 =3 7 .8 , P c o2 =9 7S O

History:History:

35 years old Omani lady Not k/c/o any previous medical problem Brought by her husband, unresponsive after

witness intentional ingestion of 20 tab amitriptyline and 10 tab Diazepam of her husband medication (from Ibin Sina for alcohol detoxification )after a social conflict with her husband at around 9:00 am

After ingestion pt was agitated went out of house and her husband put her in his car and brought her to hospital in the way she LOC

Management: Management:

Suction done Oxygen musk Connected to continues monitor NG Tube inserted Gastric Lavage done Activated Charcol given IV fluid started Inj. Nalxone given Inj. Flumazenil 0.2mg Investigations doneBlood work upCXR

Blood work up:Blood work up:

CBC: Hgb=13.2, wbc=9.8, plt=310 U&E: Na=138, k=3.8, hco3=22, CL=106, U=2.3, creat=62, Mg

: 0.86 LFT: TBL=11, ALT=14, ALP=73, alb=35 Bone: Ca=2.32, c-ca=2.42, pho=0.88 Coagulation profile Drug level:• Salicylate= < 300• Paracetamol= <66• Carbamazepine= <8.5

Cont…Cont…

Patient condition was not improving Intubated in A&E by Anesthetist Seen by medical on call (advice infusion

Flumazenil) Admitted in ICU for 24 hours Her condition improved with no

complications Extubated on 5/2/2010 shifted to ward then

discharged on 9/2/2010

PITFALLSPITFALLS

CYCLIC ANTIDEPRESSANTS CYCLIC ANTIDEPRESSANTS

OVERDOSEOVERDOSE

7 MAJOR 7 MAJOR PHARMACODYNAMIC PHARMACODYNAMIC EFFECTSEFFECTS

Second most common cause of death in drug overdose

ACTION COMPLICATION

1. Na channel Blockade:

3. K channel Blockade

5. Adrenoreceptor blockade

7. Inhibit reuptake of norepinephrine and Serotonin

9. Anticholinergic effects

11. Antihistaminic effects12. Indirect GABA

inhibition

prolong QRS and negative Inotropic effect

Prolong QT and arrhythmias

Hypotension, tachycardia

Agitated delirium and seizures

Tachycardia, mydriasis hyperthermia, urinary retention, ileus

GENERAL GENERAL APPRACHAPPRACH

Decrease level of consciousness Respiratory depression Hypotension Dysrhythmia Conduction block Seizure

QIUZ:QIUZ:

Which two of following are contraindicated to be used in treatment of TCA:

2.NaHCO33.Hypertonic saline4.Physostigmine5.B-blocker6.Lidocaine

Which of following is effective in treatment of Torsades de Pointes associated with TCA overdose:

2.Lidocaine3.Dopamine4.NaHCO35.Magnesium6.Adenosine

What is the first line in treatment of seizure associated with CA overdose:

2.Phenytoin3.Phenobarbital4.Benzodiazepines5.Carbamezapine6.propofol

TAKE HOME MESSAGETAKE HOME MESSAGE

*Drug Over dose is not uncommon

*If pt present with (Anticholinergic symptoms + CNS depression + wide QRS),,,, Consider TCA over dose until proven other wise*Benzodiazepam overdose mainly treated by Supportive care

*Never use Flumazenil in diazepam co-ingestion

ThANk YOu