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Chronic TCA Poisoning and Hypoxic Brain Injury Case Study

Explore a case of chronic tricyclic antidepressant poisoning leading to hypoxic brain injury. Follow the patient's journey from initial seizure to rehabilitation and discharge home.

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Chronic TCA Poisoning and Hypoxic Brain Injury Case Study

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  1. Dosing By Body Weight?

  2. Ms KB • 29 yr female • Generalised seizure 1st episode • Presented to local GP run hospital

  3. History • Tonic clonic seizure witnessed by partner • Self terminated after < 10 minutes • Ambulance transfer to local hospital • On arrival agitated, settled following IV diazepam

  4. Past history • Fibromyalgia • Sjogren’s Syndrome • Meningococcal meningitis 1994 • Depression • Morbid Obesity

  5. Medications • Amitriptyline 50 mg QID • Panadeine Forte q 6 h • No Known Drug Allergies

  6. Background History • 3/52 dizzy spells, falls, difficulty in sentence formation • 1/52 poor balance, intermittent blurred vision • In bed for previous 48 hours • Fell as attempting to walk to lounge, hit head, generalised seizure, non responsive for 10 minutes

  7. Initial Examination • BP 135/85 mmHg, Pulse 85, 100% sat on RA • GCS 12, irrational and aggressive but no focal neurological signs • CVS, Resp, Abdo unremarkable

  8. Investigations • ECG sinus tachy 95 bpm, QRS 140 ms

  9. Treatment • Diazepam 10 mg IV • Oxygen • Transferred by road to DGH

  10. At DGH • Alert and cooperative • BP 138/77 mmHg, pulse 101 • Examination unremarkable • ECG @ 12.40 shows QRS of 120 ms • Commenced on cardiac monitoring • Head CT arranged

  11. Subsequent events • Cardiac Arrest 1345 h in toilet • Found in asystole • Cardiac output restored @1405 • Given NaHCO3 • Retrieval to Newcastle Mater ICU

  12. Mater ICU • Pulse 80 BP 140/80 mmHg • Aspiration R LL • GCS 5 • Asystolic arrest due to amitriptyline, probable hypoxic brain injury

  13. Mater ICU • Medications as taken • Amitriptyline 200 mg QID • Panadeine Forte 4 tabs q 6 h • For 5 months duration • Asystolic arrest due to amitriptyline, probable hypoxic brain injury

  14. Subsequent History • 3 days later remains intubated, eye open to voice, purposeless limb movements, does not obey commands • Extubated on day 13, sent to ward, feeding by NGT • Referral to rehab • Day 27, following one stage commands, commenced oral feeding

  15. Outcome • Day 32 discharged to rehab • Hypoxic brain injury • Discharged home to care of husband

  16. Chronic TCA poisoning

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