29 year old female: Unresponsive

Thanks go to an anonymous reader for this excellent case, as always we hope you find it as interesting as we did! As always, details have been changed where appropriate to protect patients and providers.

You're on an ALS fly-car dispatched for an unresponsive female, a BLS ambulance and engine company are already en-route.

You arrive to a small townhome in a quiet retirement community, finding the engine and BLS unit on scene already; a firefighter is in the doorway waving you inside. He grabs your monitor and directs you to a back bedroom.

The crew has already moved the patient to the floor, placed an OPA, and is assisting ventilations. A panicked young man is pacing on the other side of the bed. One of the firefighters places your patient on the monitor. You introduce yourself to the young man–her boyfriend–and get a quick history.

"She's not been herself today, depressed and crying. This is her grandmother's house, she died two days ago."

When asked about medication usage, medical problems, or other pertinent history he says he's not sure, but that she's tried to commit suicide in the past.

One of the BLS providers gives you the initial vitals:

  • GCS: E1V1M4, "no problems with the OPA"
  • Pulse: 75 bpm, no radials, weak carotids; "but the monitor says 140 bpm"
  • BP: 62/38
  • RR: 6, now assisted at 12
  • SaO2: 70% prior to ventilations, 77% @ 15 L/min
  • BGL: 192 mg/dL (10.6 mmol/L)

The initial rhythm strip is torn off and handed to you as they package the patient for transport.

A quick physical exam reveals no trauma, clear and equal lung sounds, 5mm equal and reactive pupils. A quick scan of the room finds no medicine bottles, but the boyfriend remembers her grandmother taking medication for depression.

In the back of the unit the BLS crew obtains a 12-Lead at your request while you start an IV.

The interpretive statement reads Atrial Fibrillation with Rapid Ventricular Response and Left Bundle Branch Block. It is a 20 minute ride to the nearest hospital.

What does the rhythm strip show?

What does the 12-Lead ECG show?

What is your working diagnosis and treatment plan for this patient?

29 Comments

  • liz says:

    Rhythm strip shows a widened QRS at a rate of 75 (the monitor is reading her peaked T's as complexes). Based on the story, I'm going to go ahead and guess that the grandmother was on tricyclic antidepressants and you're looking at a TCA overdose. It'd be swell to locate the bottle to confirm, but that story and wide QRS are pretty classic. Intubate to protect the airway and transport. She's going to end up needing a boatload of sodium bicarb to reverse the metabolic acidosis.

  • Gary says:

    I agree with Liz.  Treat the patient and not just the monitor, the story leads more to an overdose on tricyclics, and the findings on the monitor confirm that suspicion. Secure airway, start pushing bicarb enroute.

  • Bryce says:

    Agreed, TCA Overdose. IV, secure the airway, continue to monitor vitals, begin Tx of sodium bicarb 1mEq/kg en route to hospital. Also once airway secured, monitor capnography as well.

  • alex says:

    Suspected overdose-> respiratory depression -> I’d be tempted to narcan her.

    Low BP & unresponsive -> fluids & O2

    Take her to the nearest hospital. the ECG is interesting but, aside from making me wonder if she might arrest, it wouldn’t change my treatment.

  • those are some ginormous T waves

  • Adam says:

    ECG certainly suggests a metabolic imbalance. As a London medic, we can’t give anything for TCA overdose which looks likely, so treating the symptoms and blued to the nearest A&E unit. For us naloxone hydrochloride would be indicated, but wouldn’t be that useful as it has very specific pharmacodynamics.

  • Medic 22 says:

    Agreed. Hyperacute T waves and wide QRS, along with the hx of suicide lead me down the TCA OD path.

  • Eric Paulson says:

    IV access, Fluid Challenge(s) to restore BP systolic above 90. Take a rider in the event of a code. Narcan to increase the respirations, though I am fairly positive due to 5mm and reactive pupils that its not a narcotic overdose. 
    The Hx of attempted suicide and grandmother using medications for depression is tricky. I'll be honest, i wouldn't of thought of that, but i'm barely a one year medic, so i'll take that as experience. TCA overdose evident of the T waves that are wide and bizarre, but I would of liked to confirm from a nearby bottle/medicine cabinet in the residence. Would it be wrong to push Bicarb in the field without that verification? and i assume get a second IV line if you did.

  • Troy says:

    I’d go with TCA OD but also check to see if granny is missin a bottle of K+. Airway, IV, bicarb, and calcium.

  • Bruce says:

    The medication bottles would be really helpful, but I agree it is likely a TCA OD.

    Also consider that grandma is probably taking either a beta/CA channel blocker or ACE inhibitor. This is also a very real possibility. You don’t see as many TCA Rx that more because there are safer meds available.

    It is possible that this rythym is 3rd degree block with burried T-waves inside perfusing unifocal PVC. The bigeminy PVCs may account for the carotid pulse of 75.

    ETT, IVF NSS wide. Narcan, Dex stick. Consider Bicarb, Atrpoine, Pace, CaCL, Glucagon, Pressors.

  • Paul E. Morris ~ CMA RMA MST EMT says:

    Our Protocalls require starting Compressions when a Patient has regains a spontaneous Pulse, and has a Systolic of 60mm hg. In this Case it might not hurt to start Compressions to assist in O2 movement to the Brain. Not.a true PEA yet pretty darned close. If Blood is not flowing radially, how do we expect it to get upstairs? As per Chemicals, no clue. A good Cardioversion should be considered. Hold her Hand, and hold Boyfriend. Huggly speaking…A herck-load of Compassion could go a long way here…

  • Philip says:

     
    Don't forget that Grandma could also been taking digitalis… If this was the case, then would it be prudent to choose lidocaine over amiodarone if the situation degraded to that point? Just a question. 

  • Adrienne says:

    My initial thought was TCA OD though it is very possible that grandma was on other meds the boyfriend didn’t know about. I would be sending someone to check all the garbage including outdoors while we package the patient, continue support measures including fluid boluses and based on the ECG and the rest of the presentation get a base order for bicarb during transport. And, yes, intubation is definitely a consideration especially if we have a long transport.

  • Dr Kashif says:

    Hyperkalemia secondary to metabolic acidosis due to TCA overdosage.
    Besides reversing effect of TCA using alkalinizer Sodabicarbonate, intravenous Calcium Choloride is more important to protect heart.

  • Nick Gardinier says:

    All the signs/symptoms of a TCA overdose. Starting with the most obvious, a loss in the family, crying all day, hx attempted suicide. Granny also had a hx depression, and she may very well have been taking TCAs. Looking further in, we see a decrease in mental status and hypotension. EKG reveals obviously widened QRS with peaked T waves. "The monitor says a rate of 140" because it's reading the T's as QRS's. The patient's pulse is always what you feel, not what "the monitor says". QRS widening is a classic sign of TCA overdose. In the field, we don't always have a definitive diagnosis. We form a "working diagnosis" to treat, and always provide supportive care of the ABCs. The working diagnosis for this particular case should almost certainly be TCA overdose. Keeping in mind the ABCs, endotracheal intubation is indicated, as this patient is currently unable to breathe effectively on her own. The patient's hypotension should be managed with a large IV fluid bolus (at least 1L). Moving on to specifics for the TCA, Sodium bicarbonate is the treatment of choice. Reading the discussion above, I see some people are "worried" about giving bicarb "without knowing for sure if its a TCA OD". Unfortunately, this uncertainty is just one of many we face in paramedicine. At some point, we're going to have to take risks like this in order to help our patients. Even if for some reason it's not a TCA OD, as a paramedic, you treated what you found and that's that. Regardless, most important for this pt is maintaining ABCs and prepare for arrest.
    @ Liz, Gary, Bryce: Nice! Agree 100%
     
    @ Alex: Although narcan is indicated in a wide variety of cases for "suspected OD with respiratory depression", it likely wouldn't work here due to the suspected drug of choice. However the key word there is "suspected". Since we don't know for sure what she took (could have been a cocktail of things), giving narcan is certainly worth a try. Especially since it has very few side effects.
     
    @Bruce: Not sure why we're giving atropine and/or pacing. The heart rate is 75, which is a perfectly acceptable rate. The three properties of the heart are chronotropy, inotropy, and dromotropy. In this case, it's the inotropic property, or "strength of the squeeze" that's the problem. Starling's law of the heart supports giving a fluid bolus in hopes of increasing the strength and therefore the blood pressure. If this fails, moving onto pressors would be the next choice.
     
    @Paul: Again, the heart RATE is not the problem. Cardioversion is not only unnecessary in this case, but it would in fact be detrimental. Electricity will not increase blood pressure. Fluids and pressors are needed…
     
    @Philip: Digitalis has more of an effect on the rate. Most commonly used in a-fib patients to control their rate. The effects of lidocaine and amiodarone also cause a decrease in heart rate. Not sure why we would use either lido or amiodarone if dig OD is suspected.
     
    On a side note, I've done three TCA ODs in the last year. They're more common than I thought!

  • Kris says:

    I'm feeling late here, but agree that this is likely a TCA overdose.
    Manage the airway as needed, sounds like intubation at this point to me. Sodium bicarbonate 1-2 mEq/kg bolus with a drip as needed. It also sounds like this overdose is fairly recent, so gastric lavage and activated charcoal may be indicated. Norepinephrine drip may be needed for the hypotension if it persists. Be ready for seizures and worsening of the ECG to a ventricular arrythmia.

  • Bren says:

    I agree, most likely TCA Overdose.
    My protocols call for 100mls 8.4% NaHCO3 given over 3 mins, repeated after 10 mins if no change. Manage hypotension with fluid +/- pressors (we use adrenaline) if required. 
    Withhold Narcan – if its not narcotic OD and you need to RSI you are limited in what you can do….
    If SPO2 unable to be raised ?90%  (? Aspiration etc) with 100% O2 via BVM or no improvement to GCS (>9) after oxygenation/perfusion management, we would RSI patient, and mildy hyperventilate (ETCO2 to 20-25 mmHg instead of 30-35 mmHg) to further attempt to reverse acidosis maintain/protect airway.

  • VinceD says:

    Great comment from Nick Gardinier that pretty well sums everything up.

    The main thing I'd add to the discussion is that I would be quite willing to give naloxone to this patient, even though very few protocols like to give it anymore if opioid overdose is not overtly suspected. The chance of co-ingestion in a case like this is very high, and with her breathing where it is, any increase in respiratory drive will be useful in countering what must be an extremely acidotic state with the combination of hypoventilation and (possible) TCA overdose. This is especially important because she will undoubtedly be intubated unless she magically jumps up after the naloxone, and in her current state, even a few seconds of apnea might push her over the edge into cardiac arrest. Also worrying is that with ventilations and high flow O2, her pulse ox is only 77%. Since it appears she has good air entry from the description above, I'd be checking my equipment as someone young and healthy like her should be pinking up with assisted ventilations and 15 Lpm.

    This is definitely a case where immediate first pass success will be required, and it is probably worth it to hold off on intubation until her sat comes up and we can blow off some CO2 with that old nemesis, hyperventilation.

    ECG shows sinus rhythm w. an axis of ~80, QRS widening, tall (should I call them peaked?) T-waves, and first degree AV block. I'm not entirely familiar with TCAs, however I'd expect the patient to be a bit more tachycardic at the moment, so I'd aslo be a little suspicious of a beta or calcium channel blocker ingestion as well (high sugar would have me leaning towards CCB, but there's a lot of reasons why her sugar could be elevated right now so it's not worth chasing zebras).
    Based on the ECG, even if it's not specifically a TCA she overdosed on, it's likely a medication with sodium channel blocking effects, so I believe sodium bicarb administration would be warranted. I'd be administering that with med control, however, since I'd be on the line with them for consideration of activated charcoal anyway. Calcium probably wouldn't hurt, but I don't know if it would help either, and our region doesn't carry it in the field anyway, so that's a good excuse for me to not worry about it. A couple liters of fluid would also be indicated to fill the tank, and if her pressure was still down with those, it would be time to start prepping dopamine, our field pressor of choice here. Very interesting case, I'm very interested in the follow-up and her actual diagnosis.

  • Wow, hard one!  In addition to TCA overdose, it could be OD of other sodium channel blocking agents such as procainamide, flecainide, etc.  These also respond to sodium bicarb.  Hyperkalemia from potassium supplements is possible, too.  Giving both bicarb and calcium might help.  Fascinating case!  I can't wait for the outcome!
    Steve Smith, Dr. Smith's ECG Blog

  • Lance says:

     
    Is the patient noticeably hyperthermic?  If so that would correlate with TCA overdose.  Great case!

  • David Baumrind says:

    Great comments so far!  

    Just to throw this out there, there is one ECG finding that is considered "typical" for TCA overdose that is not present on this ECG… Any thoughts about that?

  • VinceD says:

    David – Indeed, I was curious about the lack of a terminal R-wave in aVR, but the rest of ECG just had that "sodium channel blocker" look about it

  • David Baumrind says:

    @Vince: agreed!

  • Rob M says:

    Wide, bizzare QRS's; tall, peaked, hyperacute T waves; unresponsive patient.  TCA OD is high on the list given granny's history of depression, however life-threatening hyperkalemia also comes to mind.  Was granny a regular customer for the BLS crews prior to her passing 2 days before?  Perhaps those crews may know a bit about the history or meds.  This is not a situation to stay & play while trying to find meds that may or may not be around.  As for intubation, while its on the list of interventions to conisder, how is our bag compliance, do we have good chest rise, are we oxygenating the patient, would we be doing more harm than good by intubating the patient?  I personally am not a big fan of dropping a tube in a moving unit (unlike many other medics I know).  If I think that a tube is in order, than I'd like to take the extra 2 minutes & tube her before moving (allows for surer ventilations on the way to the rig), while some of the crew members quickly look for any pill bottles she may have had access to.  My personal thought is that she probably wouldn't have taken them too far to dispose of them.  I'd push Narcan for the respiratory depression, give fluids wide open (assuming clear lungs), transmit the strip & consult for Calcium Chloride (0.5-1g slow IV), Sodium Bicarbonate (1mEq/kg), & a standing order for dopamine should the fluid bolus fail to bring her SBP up to 100.  I'd also like to drop a second IV to facilitate pushing my meds while still running fluids (as well as the possibility of dopamine later).  That being said, as the sole ALS provider in this scenario, I'd say thats quite a bit to accomplish with just me.  As I'm in a chase car, I'm brining the tech off the ambulance and a firefighter as well in case the patient codes & letting the officer on the the engine or the other firefighter (should they be so lucky to have 4+ person staffing) drive my car to the ER.

  • Reid says:

    I’m not entirely convinced of TCA OD… Certainly some evidence for this, but I would expect tachycardia, not a normal rate. Also, I don’t remember learning anything about tall, tented, peaked, etc T waves in TCA ODs, but I could be wrong. Additionally, the boyfriend didn’t mention any agitation or HA, and there is no evidence of seizures/seizure-like activity… Hallmarks of TCA OD.

    Regardless, pre-hospital treatment would be very similar, TCA OD or not- ETT (GCS <8, not to mention poor sats and decrease resp. rate), IVx2, fulid bolus wide open (consider pressors if no response), bicarb if we're still leaning towards OD.

    Hx of SI and attempts, irregular behavior coupled with the pt's recent loss, and the pt's presentation certainly steer us towards an OD of some sort, which brings up a question about activated charcoal- how many of you carry/use NG or OG tubes so you could administer activated charcoal?

    my only other thing would be to transmit the 12 lead to the receiving ED (if technology allows) and see what med control has to say.

  • John says:

    Looking at the rate is the difference and I would go with hyperkalemia as the cause.  I would expect to see a wide complex tachycardia with TCA OD.  There appears to be the possible begining of a BBB with the 12 Lead which points to hyperkalemia also.
    Airway control to prevent aspiration if LOC improves with treatments.  Bicarb, Calcium, Glucose and Insulin if available and airway control.  Repeat 12 leads to verify treatments.

  • Richard says:

    Severe Hyperkalaemia
    TCA overdose

  • Mike says:

    Looks like TCA overdose. Secure airway, Bilateral large bore IV's. If your protocol's allow Sodium Bicarb, let her rip. High flow diesel to the ER.

  • MediMike says:

    Consider the bottomed out BP as a potential factor in the low sPO2.  Crappy distal perfusion will lead to crappy pulse oximetry.

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