Question of the Week # 388

388)  A 58 year old man with history of  severe depression is brought to the emergency room with altered mental status. He has been on treatment with amitryptyline for depression for many months. He is accompanied by his wife who reports that they had re-filled one month supply of amitryptyline a week ago but today she discovered an empty bottle at his bedside.  He There is no history of fever, nausea, vomiting or diarrhea. There is no evidence of  any witnessed seizure.  On examination, he is disoriented and lethargic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%. He does not respond to verbal commands. Gag reflex is present. Respiratory examination is normal with out any wheezing, rhonchi or crepitations. Cardiac examination and abdominal exam is benign. Intravenous Naloxone and Thiamine were administered in the field without any response. An electrocardiogram is normal. Serum electrolytes and complete blood count, finger stick glucose and arterial blood gases are within normal limits. The patient is intubated and is placed on ventilator. Which of the following is the most appropriate next step?

A) Activated Charcoal

B) Procainamide

C) Sodium Biacrbonate

D) Lidocaine

E) Amiodarone

Question of the Week # 387

387)  A 56 year old man with history of depression and hypertension is brought to the Emergency Room by his sister for altered mental status. There is no history of fever, nausea, vomiting or diarrhea. There is no evidence of  any witnessed seizure. She is not aware of what medications he takes. On examination, he is disoriented and lethargic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 80/40 mm Hg, Oxygen saturation 98%. He does not respond to verbal commands. Gag reflex is present. Respiratory examination si normal with out any wheezing, rhonchi or crepitations. Cardiac examination and abdominal exam is benign. Intravenous Naloxone and Thiamine were administered in the field without any response. An electrocardiogram is normal. Serum electrolytes and complete blood count, finger stick glucose are within normal limits. Arterial blood gases does not show any acidemia. A urine drug screen reveals:

Cocaine  – Negative

Amphetamines – Negatives

Benzodiazepenes – Positive

Opiates – Negative

Cannabis – Negative

Tricyclic Anti-Depressants – positive

A suction of his airway and central line are placed and he is started on intravenous fluids. His systolic blood pressure remains in 70 to 80 mm Hg range

Which of the following is the most appropriate next step?

A) Activated Charcoal

B) Intravenous Flumazenil

C) Serum Alkalinization

D) Start Norepinephrine

E) Intravenous Lidocaine

%d bloggers like this: