Emergency Medicine ST4 Simulation Course
Patients Name: Penny Tapp
Patients Age / DOB: 16 years old
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Major Problem |
Medical TCA Overdose |
CRM Team working Allocation of tasks Communication with other teams
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Learning Goal
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Medical Recognise TCA OD Understand initial treatment
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Narrative Description
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Young girl who has taken a TCA OD about 1 hour prior to admission. Patient is initially slightly drowsy and disorientated and then becomes unresponsive with decreased respiratory rate and hypotension. Patient will need ITU care |
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Staffing
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Faculty Control Room: 1 x Sim man controls 1 x Pt voice
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Faculty Role Players: 1 x Nurse 1 x Mother / father 1 x ITU registrar |
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Case Briefing
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To All Candidates A 16 yr old girl is brought into the ED by her mum with altered mental status. Mum reports she came home from school upset and tearful, wouldn’t talk about it and asked to be left alone. 30 mins later mum went to check on her and found her with altered consciousness and brought her to ED. |
To Role Players Mum is initially worried that her daughter has been taking drugs. As her daughter becomes more unresponsive she puts her hand in her pocket and discovers that her amitryptilline is missing. She knows it was definitely in there previously. Consultant toxicology / toxicology help line. ITU registrar. |
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Manikin preparation
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Manikin dressed as per a young girl. 1x IV cannula in right ACF. Obs. chart, A&E notes and blood results / ECG (prolonged QT) / ABG / guidance on TCA OD all available for the candidate on request. |
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Room set up |
As per A&E resus room.
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Simulator operation
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After initial evaluation (vital signs, physical exam), patient will become unresponsive, decreased RR, and hypotensive. Patient will require intubation, may receive decontamination with activated charcoal after intubation, IVF, sodium bicarbonate, vasopressor (Levophed, Neosynephrine), and ICU unit admission. Toxicology consultation should be requested but will have no additional suggestions. |
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Props needed |
Wig and bra for young female, ID wrist band. Sodium Bicarbonate 8.4% - 50-100ml bolus’ Lidocaine (100mg IV), Activated charcoal. Intubation equipment, cardiac monitoring, ECG, CXR. |
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Observations:
Initial
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Par score |
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HR |
112 |
2 |
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O2 sats |
100% on 2 L |
0 |
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BP |
105 / 50 |
0 |
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Temp |
38.5 |
1 |
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RR |
16 |
0 |
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GCS |
E= 4 V= 3 M= 5 Total = 11 |
1 |
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Pupils |
Large, not reactive |
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Total Par Score |
4 |
Over first 5-10 mins
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Par score |
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HR |
132 |
3 |
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O2 sats |
100% on 2L |
0 |
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BP |
80/50 |
2 |
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Temp |
38.2 |
1 |
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RR |
8 |
2 |
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GCS |
E= 1 V = 2 M = 3 Total = 8 |
3 |
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Total Par Score |
11 |
With no treatment pt will decompensate
Failure to intubate
Asystole
If given flumazenil
Patient starts fitting and rapidly deteriorates
Treatment is with benzodiazepines
No IV fluids
Hypotension then asystole
No sodium bicarbonate
(50 mls 8.4% titrated to pH 7.45 – 7.55)
shock refractory VT
will respond to sodium bicarbonate 50 -100 mls 8.4%
and / or lidocaine 100 mg IV
Nurse Role
Scenario
A 16 yr old girl is brought into the ED by her mum with altered mental status. Mum reports she came home from school upset and tearful, wouldn’t talk about it and asked to be left alone. 30 mins later mum went to check on her and found her with altered consciousness and brought her to ED.
Underlying diagnosis
TCA Overdose
Instructions
You are a competent A&E nurse and can find anything you are asked for but do not make suggestions yourself unless candidate is really struggling.
When you touch the patient you notice their skin is warm and dry and her lips are dry. The patient is initially confused with a GCS = 11 (E=4, V=3, M=4) and complaining of blurred vision (pupils dilated and poorly reactive). She will then develop further respiratory depression and drop in conscious level and will eventually require intubation and ITU.
Patient Role
Scenario
You are a 16 yr old girl who is brought into the ED by your mum with altered mental status. Mum reports you came home from school upset and tearful, wouldn’t talk about it and asked to be left alone. 30 mins later mum went to check on you and found you with altered consciousness and called an ambulance.
Underlying diagnosis
TCA OD
Patient Instructions
On arrival in A&E you are febrile, delirious, agitated and moaning incoherently. If questioned you vision is blurred. Over 5-10 mins you deteriorate and become unconscious.
Past medical/surgical history - None
Meds and allergies – No medications, NKDA
Immunizations – Up to date
Family/social history – Mother has depression, recently prescribed amitryptyline (can reveal with questioning or below)
Mother is widow (father died 1 year ago in car accident)
School student
No known tobacco/alcohol/drugs
LMP 2 weeks ago
Mother / Father
Scenario
A 16 yr old girl is brought into the ED by her mum with altered mental status. Mum reports she came home from school upset and tearful, wouldn’t talk about it and asked to be left alone. 30 mins later mum went to check on her and found her with altered consciousness and brought her to ED.
Underlying diagnosis
TCA Overdose
Instructions
History as above. You are very concerned and think she may have been taking recreational drugs as you know some of her friends are into that sort of thing.
You have depression and were recently prescribed amitryptyline – (you can reveal with questioning or if not picked up 10 mins into the scenario you put your hand in your pocket and realised your amitryptyline is missing.) It was a new prescription so quite a large number are missing.
You are a widow (Husband/Wife died 1 year ago in car accident)
Daughter's history
Past medical/surgical history - None
Meds and allergies – No medications, NKDA
Immunizations – Up to date
Family/social history – School student
No known tobacco/alcohol/drugs
LMP 2 weeks ago
You think your daughter may have broken up with her boyfriend today which may have precipitated this but only reveal if asked.
You are happy to move away from the bedside but do not want to leave the room. If you are not kept informed of what is happening you become distressed and interfering.
Blood results Penny Tapp, 16 years old
WBC 6.5 Na 135
HGB 13 K 3
PLT 375 Urea 2
Cr 121
Glucose 5.8
Paracetamol negative
Salicylate negative
ABG
Pre-intubation
pH 7.25
PCO2 6.0
PO2 15.1
HCO3 22
O2 Sat % 90
Urine HCG: Negative
If relevant for participating hospital:
Urine drugs-of-abuse screen: + TCAs
Serum toxicology screen: + TCAs
ECG: Penny Tapp, 16 years old (TCA Overdose)
Chest X-Ray: Penny Tapp, 16 years old (TCA Overdose)
Tricyclic Antidepressant Overdose Guidance
A partial list of potential signs and symptoms suggestive of TCA overdose include:
- Known or suspected ingestion
- Coma
- Seizure
- Acidosis
- Hypotension (SBP < 90)
- Tachycardia
ECG Changes
- Prolonged PR interval
- Prolonged QRS greater than 0.1 seconds
- Prolonged QT interval
- Rightward shift of the terminal 40 milliseconds of the frontal plane QRS vector (Deep S wave in Lead 1 along with large R wave - greater than 3 mm height - in a VR) (sensitivity 0.83; specificity 0.63)
- Ventricular arrhythmias
Anticholinergic signs/symptoms
- Dry mouth
- Mydriasis
- Urinary retention
- Ileus
- Confusion
Measurement of plasma level of TCA not readily available or particularly helpful
Treatment
Maintain airway breathing and ventilation
Gastric lavage if substantial amount ingested (>20-30mg/kg) within 1 hour
Beware of risk of pushing contents beyond pylorus and enhancing absorption!
Do not wash out conscious pt as large absorption clearly already taken place
Activated charcoal via mouth or NG tube (50g for adult) if >10mg/kg taken in last hour.
In severe toxicity consider second dose of charcoal after 2 hours.
For agitation use diazepam – as well as for seizures.
Cardiac monitoring is essential if significant ingestion has taken place – usually for first 24 hours.
Sodium bicarbonate, 50mls of 8.4% IV should be given IV (even in absence of acidosis) in all patients with QRS prolongation, arrhythmias or hypotension. Give repeat doses by bolus aiming to keep pH between 7.45 and 7.55.
(Acts by increasing extracellular sodium concentrations and by increasing pH)
If multiple arrhythmias occur, particularly if there is evidence of AV block, transvenous pacing is required.
If VT with absence of TV pacing wires in situ, 50-100mls 8.4% sodium bicarb should be given and then lignocaine 100mgs i.v.
SVT’s with haemodynamic compromise – use atenolol or esmolol.
If patient does arrest, do not give up early, pts have survived after at least an hour of CPR.
Resistant hypotension – 10mg of i.v. glucagon has been used with some success.
Peritoneal dialysis, haemodialysis and charcoal haemoperfusion are all ineffective.