TCAS-ASSOCIATED WITH PERSISTENT WIDE COMPLEX VENTRICULAR TACHYCARDIA

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Amitriptyline is a tricyclic antidepressant (TCA) that has been used for over 50 years. TCAs are notorious for cardiotoxicity and neurotoxicity, and it is widely used medication for suicide. The incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF) is approximately 4% in TCA overdose patients. It is mostly noted in patients with severe acidosis, hypotension, and prolonged QRS duration. Here, we present a patient with prolonged wide-complex ventricular tachycardia secondary to amitriptyline overdose. CASE PRESENTATION: A 50 year old female with history of Ehlers-Danlos syndrome and fibromyalgia was brought to the ED by her husband because of a reported seizure at home. Pertinent home medications included Amitriptyline, fentanyl patch, and hydromorphone. Patient denied any prior history of heart disease or neurological problems. On arrival to the ED, Glasgow Coma Scale was 3. Pertinent vital signs were blood pressure of 61/35 mmHg. The patient was emergently intubated. ECG on admission showed slow wide complex VT (80 bpm with QRS duration 217 msec. Admission labs showed elevated anion gap metabolic acidosis. Lactic acid was 20.0 mmol/L. ABG post intubation showed pH 7.17, pCO2 44, pO2 240 with base excess of -12. Urine toxicology demonstrated TCAs and opiates. Naloxone 4 mg IV was given twice with no improvement in symptoms. Repeat ECG 2 hours later showed wide complex ventricular tachycardia 158 bpm with QRS prolongation 178 msec. This was initially thought to be sinus tachycardia with prolonged QRS complex. ICU was consulted and the patient was immediately cardioverted upon arrival to the MICU. Sinus rhythm was achieved, but the patient remained tachycardic. EEG was obtained which confirmed 7 left and 5 right mid-temporal lobe seizures. Patient was started on bicarbonate gtt and Ativan gtt. ECG and ABG were obtained every 4 hours. Her QRS duration normalized and the acidosis has resolved after 12 hours. Brain MRI with and without contrast did not show any acute intracranial pathology. The patient was discharged home safely after a 7-day hospitalization. DISCUSSION: TCAs have been used for over 50 years for the treatment of depression and neuropathic pain. It has many side effects including cardiotoxic and neurotoxic adverse outcomes. The severity of cardiotoxic effects are also imperative to recognize; particularly, it is important to suspect TCA toxicity in a patient with persistent wide complex ventricular tachycardia. Patients with VT secondary to TCA overdose, should promptly treated with the ACLS protocol. These patients should be closely monitored in the ICU and should receive sodium bicarbonate gtt, ABG, and EKG every four hours. CONCLUSIONS: Early recognition and aggressive intervention is warranted in patients presenting with TCA overdose in order to improve patient outcomes. Reference #1: Goldberg RJ, Capone RJ, Hunt JD. Cardiac complications following tricyclic antidepressant overdose. Issues for monitoring policy. JAMA 1985; 254:1772. Reference #2: Khandker Mohammad Nurus Sabah, Abdul Wadud Chowdhury, Mohammad Shahidul Islam, Bishnu Pada Saha, Syed Rezwan Kabir, and Shamima Kawser. Amitriptyline-induced ventricular tachycardia: a case report. BME Res Notes. 2017;10:286. https://doi.org/10.1186/s13104-017-2615-8 DISCLOSURES: No relevant relationships by Abdisamad Ibrahim, source=Web Response No relevant relationships by Mohamed Labedi, source=Web Response No relevant relationships by Ruby Maini, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response