There are multiple possible causes for reduced consciousness and they’re not infrequently toxic. Although intoxication is common and obvious, this is a rare case due to tricyclic antidepressants overdose.
Case Report
A 76-year-old woman presented to the ER unconscious with possible aspiration and vomit in the oropharynx. She looked neglected and her weight was under normal. Furthermore, the patient was unresponsive, her pupils were 6mm in diameter and the Glasgow coma scale was 3. The doctors also intubated her immediately for her for airway protection, mechanically ventilating her.
Her ECG on admission revealed an intraventricular conductive disorder. Moreover, her qualitative analysis for drug abuse was negative and CT angiography of the head showed no signs of ischemia or occlusion of the intracranial vessels.
Doctors transferred her to the ICU and the EEG showed diffuse non-specific nonepileptiform background slowing. It is a common observation in patients with encephalopathy or drug intoxication.
Self-Medication for Anxiety and Depression
The family clarified the next morning that the patient suffered from depression and anxiety. In addition, suffered from poor performance and weight loss. She went to bed around midnight and her family found her in a coma around noon. Her medical history revealed that she was under prescription amitriptyline intermittently from 2014 to September 2019. However, she possibly self-medicated with amitriptyline since it wasn’t prescribed for a year prior to her admission.
Upon suspicion of TCA intoxication, doctors determined her plasma levels. Her plasma concentration was higher than 500 μg/L for amitriptyline and nortriptyline, which is potentially toxic.
Treatment and Recover
Her GCS improved three days after admission and was normal on the seventh day. Psych evaluation showed no signs of overdose or suicide attempt. Doctors discharged her on the tenth day.
Conclusion
The patient is thought to have taken many tricyclic antidepressants (amitriptyline) at once, leading to intoxication. This led to an unusual and long persistence of comatose.
