A 40-year-old man is brought to you by his friends. Apparently, he has ingested some unknown medication in a suicide attempt. The patient is disoriented to time. His temperature is 103 F, BP is 120/85 pulse 100/min and irregular, and respirations are 22/min. The skin is flushed and dry. Dilated pupils and muscle twitching are also noted on examination. ECG reveals prolonged QRS complexes. Hepatic transaminases are normal, and ABG shows a normal pH. These findings are most likely due to intoxication by which substance?
This patient's clinical picture is consistent with intoxication with tricyclic antidepressants such as amitriptyline and imipramine. Toxic effects are mediated by peripheral anticholinergic activity and "quinidine-like" action. The anticholinergic effects include mydriasis, tachycardia, impaired sweating with flushed skin, dry mouth, constipation, and muscle twitching. Quinidine-like effects (due to block of sodium channels in the hea) result in cardiac arrhythmias, especially ventricular tachyarrhythmias. In this setting, prolongation of the QRS complex is paicularly impoant in the diagnosis. QRS width is, in fact, an even more faithful parameter of drug toxicity than serum drug levels. In severe intoxication, patients will develop seizures, severe hypotension, and coma. Acetaminophen results in liver toxicity. Liver enzymes would be elevated. Alcohol intoxication manifests with respiratory depression, hypothermia, and coma. The manifestations of benzodiazepine intoxication are similar to alcohol inasmuch as central nervous system depression is common to both drugs. Thus, acute benzodiazepine intoxication produces stupor, coma, and respiratory depression. The sympatholytic propeies of clonidine explain the clinical symptoms of intoxication. Clonidine overdose causes bradycardia, hypotension, miosis, and respiratory depression. Monoamine oxidase (MAO) inhibitors represent a second-line treatment for major depression. Overdose induces ataxia, excitement, hypeension, and tachycardia. Such reactions can be precipitated by concomitant ingestion of tyramine-containing foods. Reference: Kaplon and sadock, 11 th edition, synopsis of psychiatry, 11 th edition, pg no. 1144
Acetaminophen
Alcohol
Benzodiazepines
Tricyclic antidepressants
Treatment in psychiatry