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Flumazenil
7%
4/61
Sodium bicarbonate
48%
29/61
Obtain blood cultures then begin IV antibiotics
0%
0/61
Naloxone, thiamine, and dextrose-containing IV fluids
38%
23/61
Observation
8%
5/61
Select Answer to see Preferred Response
This patient is presenting with an unknown intoxication and QRS widening on EKG suggesting a diagnosis of tricyclic antidepressant (TCA) overdose. The best initial step in management is sodium bicarbonate. TCA overdose presents with anti-cholinergic symptoms which include dry eyes, dry mouth, dry hot/flushed skin, constipation, and altered mental status. However, the most specific finding and best indicator of toxicity is the EKG finding of QRS widening. Suspect TCA intoxication in the presence of QRS widening even if there is no history of depression or TCA exposure. The best initial step in management is sodium bicarbonate which is cardioprotective (via increased sodium load, and alkalinization). Figure A is an EKG that demonstrates QRS widening on EKG which is a specific indicator of TCA toxicity. Figure B is a head CT that is within normal limits. Figure C is a chest radiograph that is within normal limits. Incorrect Answers: Answer 1: Flumazenil can be used in severe cases of benzodiazepine intoxication. Patients who are intoxicated with benzodiazepines present with decreased respiratory rate, and are typically sedated and would not have the EKG findings in this case. In general they should not be given flumazenil as this can precipitate withdrawal, or even a withdrawal seizure. Answer 3: Blood cultures and IV antibiotics would be the best initial step in management if sepsis was suspected. This patient lacks any systemic symptoms that would suggest an infectious etiology. Answer 4: Naloxone, thiamine, and dextrose-containing IV fluids are the best initial step in management for intoxication from an unknown etiology in a patient who needs an intervention (unstable, a danger to themselves). Naloxone can treat opioid intoxication, thiamine can treat a thiamine deficiency that may exist in alcoholics, and IV fluids and dextrose can stabilize the patient if low blood glucose is related to the etiology. Answer 5: Observation would be the appropriate management for a stable patient with an unknown intoxication who was stable and simply needed time to detoxify. Bullet Summary: QRS widening on EKG is the most specific indicator of toxicity in cases of TCA overdose, and the best initial step in management is to administer sodium bicarbonate.
3.7
(10)
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