Category: Case Summary

Management of Life-Threatening Tricyclic Antidepressant Overdose

Management of Life-Threatening Tricyclic Antidepressant Overdose

Steve Mathieu1 Comment

A 44-year-old lady was brought to ED by ambulance after her partner found her drowsy in her bedroom with multiple empty packets of Amitriptyline scattered around the bed. The ambulance crew found no other medications in the immediate vicinity. Her partner had last seen her two hours previously that evening and described a history of depression, previous overdoses and chronic alcohol excess.  On arrival in ED, her airway was self-maintained but she had signs of vomitus around her mouth and smelled strongly of alcohol. Heart rate was 125, NIBP 92/38 and ECG showed sinus rhythm with prolonged PR and QRS intervals (240ms and 200ms, respectively). ABG showed a metabolic acidosis with lack of respiratory compensation, with hyperlactataemia (4.1). GCS was 9 (E2M5V2) although she appeared agitated with bilaterally dilated pupils. There was no external evidence of injury. The impression was of life-threatening Tricyclic Antidepressant (TCA) overdose within the last 2 hours along with alcohol ingestion.

What are the main features of a Tricyclic Antidepressant overdose? What treatment options are available?

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Hypertonic Saline for Raised Intracranial Pressure

Hypertonic Saline for Raised Intracranial Pressure

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A 40 year old male was brought into ED following a high speed road traffic accident. The patient was ejected from the vehicle. The patient was managed according to ATLS guidelines. He suffered extensive injuries including facial fractures, traumatic subarachnoid haemorrhage and multiple intra-cerebral haemorrhages, a flail chest and thoracic and cervical spine injuries. Once stabilised, the patient was transferred to the neurosurgical intensive care unit where an intra-cranial pressure (ICP) monitor was inserted to measure intracranial pressures. His ICP was persistently raised despite optimising respiratory parameters, deep sedation, muscle relaxation and then mannitol. A decision was made to commence an infusion of hypertonic saline 2.7% according to the local protocol. The ICP improved rapidly and stabilised and removed the need to proceed with surgical decompressive craniotomy.

What is the evidence for the use of hypertonic saline in the treatment of acutely raised intracranial pressure?Read More »

Neuroprognostication Post Cardiac Arrest (Post TTM Era)

Neuroprognostication Post Cardiac Arrest (Post TTM Era)

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A  young adult female with known diagnosis of poorly controlled type 1 diabetes mellitus was admitted with out-of-hospital cardiac arrest. She had only recently been discharged from hospital after an admission with diabetic ketoacidosis. On arrival she had a GCS 3 with minimal respiratory effort. She was in profound DKA. Her temperature was 34.7°C on admission to ICU and she had targeted temperature management aiming for 36°C which was achieved within 2 hours. Her pH had normalised to 7.35 within 8 hours. 48 hours later one pupil became fixed and dilated. CT brain was consistent with global hypoxic ischaemic injury. EEG and SSEP on day 3 revealed severe lack of normal cortical activity. After discussion with family, treatment was withdrawn on day 4.

How do we undertake neuroprognostication after cardiac arrest in the post-TTM era?

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Nutrition in Acute Pancreatitis

Nutrition in Acute Pancreatitis

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A 55-year-old previously healthy lady was admitted with pancreatitis secondary to gallstones. Her admission modified Glasgow Score was 4, and CT scan showed approximately 70% necrosis of the pancreas encompassing the neck, body and tail with sparing of the head. She rapidly developed ARDS, AKI and vasoplegia, and subsequently developed abdominal compartment syndrome requiring decompressive laparotomy. Her later complications included intraabdominal collections requiring percutaneous drainage, upper GI bleeding, and staged closure of her laparostomy. She was initially commenced on enteral NG feeding but developed high NG aspirates despite pro-kinetics. Parenteral nutrition (PN) was commenced in combination with a ‘trophic’ enteral feed. Four weeks into her admission her triglyceride level was found to be elevated, necessitating lipid free PN and cessation of propofol. This led to a drop in her triglyceride level.

How should we manage the provision of nutrition in acute pancreatitis?

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Dexamethasone in Bacterial Meningitis

Dexamethasone in Bacterial Meningitis

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A previously healthy 25 year old female was admitted with low GCS and a fever. She had a 24 history of viral symptoms including sore throat and a headache. On admission she had a GCS of 3, temperature of 38.9°C and raised inflammatory markers. She was intubated but did not require vasopressor support. A CT brain showed diffuse cerebral swelling, effacement of the sulci, sylvian fissures, basal cisterns and 3rd/4th ventricles, and early cerebellar tonsillar herniation. Lumbar puncture was not performed due to CT appearances. She was commenced on intravenous (IV) ceftriaxone 2g twice daily, IV acyclovir 800mg three times daily, and IV dexamethasone 10mg four times daily. Unfortunately, her pupils remained fixed and dilated on sedation hold 36 hours later, and she was making no respiratory efforts. She subsequently became a DBD organ donor.

What is the evidence for dexamethasone in bacterial meningitis?

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Corticosteroids in Septic Shock

Corticosteroids in Septic Shock

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A week after an elective colectomy, a 70yr old man developed septic shock and multiorgan failure secondary to anastomotic breakdown. He was managed according to surviving sepsis guidelines with source control, early antibiotics, fluids and noradrenaline. The patient remained hypotensive and refractory to noradrenaline therapy, and had vasopressin and low dose hydrocortisone infusion commenced.

What is the evidence for the use of corticosteroids in septic shock?Read More »

Nutrition in the Intensive Care Unit

Nutrition in the Intensive Care Unit

Steve Mathieu1 Comment

A middle aged man is admitted with abdominal pain and vomiting. He has a history of alcohol excess. A CT scan shows evidence of pancreatic necrosis. Supportive care is initiated and an NGT placed for supplementary enteral nutrition. After 3 days, he is referred to ICU as his oxygen requirements have increased and he is requiring non-invasive ventilation. It is noted that he has had very large gastric aspirates. Parenteral nutrition is commenced at this point.

What is the evidence for enteral versus parenteral feed as a source of nutrition in critically ill patients?Read More »

Tracheostomy in the Intensive Care Unit

Tracheostomy in the Intensive Care Unit

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A 47-year-old male was admitted to the intensive care unit (ICU) following a high-speed motorcycle accident. He had a number of injuries including bilateral pneumothoraces, multiple spinal fractures, an open-book pelvis fracture, and a brachial plexus injury. Bilateral chest drains were inserted and external fixation of the pelvis was performed. The patient was extubated eventually at day 15 but required reintubation within 12 hours because of a poor cough and sputum retention 

What are the indications for a tracheostomy and when shout it be considered?

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Heparin Induced Thrombocytopenia

Heparin Induced Thrombocytopenia

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A 62 year old lady with a metallic aortic valve was admitted to the cardiac unit for urgent surgical repair of a severely regurgitant mitral valve. He was normally on warfarin for his metal valve. This was stopped and unfractionated heparin commenced on day 4 once his INR level had dropped below the therapeutic range. The patient’s platelet count was 147*10^9/L on admission. By day 4 it had dropped to 85*10^9/L. After heparin was started it dropped further to a nadir of 55*10^9/L on day 8.

Could this be due to heparin induced thrombocytopenia? What investigations are required and how should we treat it?
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Hepatorenal Syndrome

Hepatorenal Syndrome

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A 54 year old man with a history of alcohol excess was admitted under the medical team with an upper gastro-intestinal bleed. He had a background of pulmonary fibrosis that limited his exercise tolerance to 30 yards. Antibiotics, terlipressin and fluid resuscitation, including blood, were given. An oesophago-gastro-duodenoscopy demonstrated severe portal gastropathy but no active bleeding or varices. An abdominal ultrasound demonstrated cirrhosis and some moderate ascites. On day two of the patient’s hospital admission he was admitted to the intensive care unit (ICU) with respiratory failure and non-invasive ventilation was started. Over the next few days his condition deteriorated and he required vasopressor support. By day 6 the patient was oliguric, and his creatinine had risen from 102 to 155 µmoles/l.

What is the cause for his acute kidney injury? Could it be hepatorenal syndrome? Read More »