What's the Diagnosis (the Critical Care edition)? By Dr. Grace Lam

35 year-old male is brought in by family after intentional overdose of unknown substance. He’s unresponsive and has the following EKG. What's the diagnosis and how should it be managed? (Scroll down for the answer)














Answer: TCA Overdose

  • The EKG demonstrates a right axis deviation with a terminal R wave in aVR, which is indicative of TCA overdose. 
  • Sodium bicarbonate boluses (1-2 mEq/kg) followed by bicarbonate drip at 2-3 mL/kg/h should be given
  • The bicarbonate drip can be created by adding 150 mEq to a 1L bag of D5W; bicarbonate therapy should be adjusted until blood pH equals 7.50 to 7.55.
  • This was recently discussed on EMDaily in some detail here.