Polypharmacy overdose

Vignette: 36 year old lady admitted to hospital after partner found her collapsed on the bedroom floor, paramedics report inconsistent GCS 14 and vomiting.

Past medical history: Depression + Anxiety

Medications: Venlafaxine 150mg OD

Observations: HR 142 bpm, BP 90/50, RR 19, Sats 96% on air, Temp 37.5

Please discuss your approach in this patient.

Model answer:

Candidate should identify this patient is clinically very unwell + haemodynamically unstable. Should be managed in resus if in ED.

Patient should be assessed in A-E manner, ensuring their airway is safe.

An attempt to get history from partner should be made – should explore the potential of overdose – time onset, any empty packets? Explore any history of previous OD? any recent traumatic events?/triggers

Examine patient clinically – dilated pupils, c/o muscle pains

Investigations: repeat obs/bedside monitoring, bloods including VBG, FBC, U&Es, CRP, glucose, Clotting, ?paracetamol level, ?salicylate level, ECG

Differentials include: Overdose – venlafaxine or polypharmacy, acute CVE/neurologic syncope, cardiac syncope

Treatment: In A-E manner, IV fluids, cardiac monitoring (may mention QT/QRS widening with venlafaxine OD), look up venlafaxine on toxbase for guidance on how long to monitor. Monitor GCS, if dropping, make ITU aware. Consider CTH.

Further History: Packets of empty venlafaxine – approx. 40 pills. Packets of empty paracetamol – approx. 20 pills, paracetamol level 10 GCS now E3, V3, M5

How would you manage this patient further?

Candidate will acknowledge that this is a polypharmacy OD including Venlafaxine and Paracetamol. They may ask for weight to calculate the total paracetamol ingested but ideally would recognise that paracetamol level is high enough to treat, mention NAC and treating as per trust protocol (SNAP protocol.)

Given GCS is low, would need to d/w senior/ITU aware now. May need urgent CTH. Update family, Psych liaison referral when medically fit for discharge.