Found drowsy at home with an empty packet of her own tablets

62-year-old woman. Found drowsy at home with an empty packet of her own tablets

Amitriptyline for post-herpetic neuralgia and ramipril for hypertension. Lives alone, no cardiac history, no previous overdose.

Stage 1 of 2

Bronwen Ellis was found by her daughter at midday, slumped in a chair and difficult to rouse. An empty amitriptyline packet was on the table beside her. She opens her eyes to voice, mumbles, and moves all four limbs. The pupils are dilated, the chest is clear, and the skin is warm and dry. This twelve-lead was recorded as she was moved onto the resus trolley, and a venous gas taken at the same time gives a potassium of 4.1.

Tracing 1 of 2 for the quiz “Found drowsy at home with an empty packet of her own tablets”. — Twelve-lead recorded on arrival in resus, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Bloods

Lactate (mmol/L): 2.4
Potassium (mmol/L): 4.1

What does the tracing show?

AMonomorphic ventricular tachycardia Your answer
BSupraventricular tachycardia with rate-related aberrancy Your answer
CSinus tachycardia with drug-induced QRS widening Correct answer Your answer
DSinus tachycardia with hyperkalaemic QRS widening Your answer

Which feature on the paper places the driver above the ventricle?

AA rightward axis, unusual for a ventricular focus Your answer
BA P wave before every complex at a constant interval Correct answer Your answer
CA rate of 112, at the slow end for ventricular tachycardia Your answer
DA QRS of 152 ms, at the narrow end for ventricular tachycardia Your answer

She remains drowsy with a systolic pressure of 96. What do you give?

AAmiodarone 300 mg intravenously, over twenty minutes Your answer
BSodium bicarbonate 8.4%, repeated against the QRS width Correct answer Your answer
CSynchronised cardioversion, under procedural sedation Your answer
DMagnesium sulfate 2 g intravenously, over ten minutes Your answer

Stage 2 of 2

Sodium bicarbonate 8.4% is given as 50 ml boluses through a large cannula, with the ECG repeated after each. She is intubated for airway protection before the third bolus and sedated for transfer. This tracing was recorded twelve minutes after the first bolus.

Tracing 2 of 2 for the quiz “Found drowsy at home with an empty packet of her own tablets”. — Twelve-lead repeated after treatment, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 96
SpO₂ (%): 99
Respiratory rate: 14
Temperature (°C): 36.3
Systolic BP (mmHg): 104
Diastolic BP (mmHg): 62

Bloods

Potassium (mmol/L): 3.6

What does comparing the two tracings show?

AThe sedation has slowed the rate Your answer
BThe ventricular tachycardia has converted to sinus rhythm Your answer
CThe QRS has narrowed while the rhythm stayed sinus Correct answer Your answer
DThe rate-related aberrancy has resolved as the rate fell Your answer

Found drowsy at home with an empty packet of her own tablets

The case

On arrival

Bloods

Observations

Bloods

Diagnosis

Discussion