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Case Study of a Young Woman Presenting to the ED with Tachycardia and Hypotension.
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Case Study of a Young Woman Presenting to the ED with Tachycardia and Hypotension.
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1Case Study of a Young Woman Presenting to
the ED with Tachycardia and Hypotension.
A young female in her 40s with a past medical history of gastroesophageal reflux disease
(GERD) and depression presented to the emergency department with tachycardia and
hypotension. Her current prescribed medications were omeprazole and amitriptyline. Upon
arrival at the emergency department, she was agitated and anxious. She was given lorazepam and
midazolam for her agitation. Her vital signs demonstrated tachycardia with heart rates in the
140s and hypotension of 80/40 mmHg. Pertinent physical examination findings were significant
urinary retention which prompted the placement of a Foley catheter. Other pertinent findings
included mydriasis, dry mucous membranes, and absent bowel sounds. An electrocardiogram
(ECG) was significant for sinus tachycardia. Immune-based drug screening panel was all
negative (Table 1), but the urine comprehensive drug screen (UCDS) by liquid chromatography-
quadrupole time of flight mass spectroscopy (LC-qTOF) is shown in Figure 1 below. Figure 1
demonstrates significant peaks for amitriptyline (retention time: 8.2 minutes), Nortriptyline (an
active metabolite of amitriptyline) (retention time: 7.9 minutes), lorazepam metabolite (retention
time: 6.0 minutes), and a caffeine metabolite or theophylline (retention time: 1.4 minutes). Upon
further discussion, the patient reported accidental supratherapeutic ingestion of
amitriptyline. She was treated with lorazepam as needed for agitation and intravenous fluid
replacement during her hospitalization. Serial ECGs did not show QRS prolongation, therefore
1
, 2
serum alkalinization was not needed. She was safely discharged home after her brief hospital
course.
Table 1
Test
THC-EIA - negative
Amphetamine-EIA - negative
Barbiturate-EIA - negative
Benzodiazepine-EIA - negative
Cocaine metabolite-EIA - negative
Methadone-EIA - negative
Opiate-EIA - negative
Buprenorphine-EIA - negative
Fentanyl-EIA - negative
2
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