An 18-year-old woman is brought to the emergency department after a suspected drug overdose at 6 AM. The mother states that she had awakened this morning to find her daughter difficult to rouse and covered in emesis. The prescription bottle of paroxetine 20 mg containing 30 pills filled the previous day was next to her and was empty. She does not know when or if her daughter took the medication. She last saw her daughter the previous evening before going to bed at 10 PM. Her daughter has a history of major depressive disorder but has no known previous suicide attempts. Temperature is 36.1 C (97 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 10/min. Pulse oximetry is 98% on room air. On examination, the patient's clothes are stained with emesis. Her eyes are closed, and she does not follow commands but moans and withdraws all the extremities to painful stimuli. The pupils are normal sized, equal, and reactive. Muscle tone and reflexes are normal. Cardiopulmonary and abdominal examinations are normal. There is no evidence of trauma. Which of the following is the best next step in management?

Question

An 18-year-old woman is brought to the emergency department after a suspected drug overdose at 6 AM.  The mother states that she had awakened this morning to find her daughter difficult to rouse and covered in emesis.  The prescription bottle of paroxetine 20 mg containing 30 pills filled the previous day was next to her and was empty.  She does not know when or if her daughter took the medication.  She last saw her daughter the previous evening before going to bed at 10 PM.  Her daughter has a history of major depressive disorder but has no known previous suicide attempts.  Temperature is 36.1 C (97 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 10/min.  Pulse oximetry is 98% on room air.  On examination, the patient's clothes are stained with emesis.  Her eyes are closed, and she does not follow commands but moans and withdraws all the extremities to painful stimuli.  The pupils are normal sized, equal, and reactive.  Muscle tone and reflexes are normal.  Cardiopulmonary and abdominal examinations are normal.  There is no evidence of trauma.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

This patient has overdosed on paroxetine, a selective serotonin reuptake inhibitor (SSRI). Isolated SSRI ingestions are generally much safer compared to overdose of other antidepressants such as tricyclic antidepressants. Patients are frequently asymptomatic or have mild CNS depression. Therefore, when a patient with an SSRI overdose has altered mental status (eg, not following commands and withdrawing to painful stimuli) or abnormal physical findings, other causes (eg, coingestions, infections) should be investigated. This patient's decreased level of consciousness and respiratory rate suggest an additional ingestant (eg, ethanol, benzodiazepine). Other coingestants that should be considered include acetaminophen and salicylates. In general, laboratory evaluation of symptomatic patients with suspected SSRI overdose should also include an ECG (although most SSRIs are not cardiotoxic, citalopram and escitalopram can prolong the QT interval), glucose level (useful in any patient with overdose or altered mental status), and serum bicarbonate level (for possible metabolic acidosis). (Choice A) Activated charcoal is a highly absorbent powder that reduces the absorption of certain substances (eg, SSRIs) in the gastrointestinal tract. It should be administered to awake, alert patients within a few hours of certain toxic ingestions. Altered mental status is a contraindication to charcoal due to risk of aspiration. (Choice B) Cyproheptadine is the antidote for serotonin syndrome in patients unresponsive to supportive measures and benzodiazepines. This patient has overdosed on a serotonergic agent but does not have symptoms consistent with serotonin syndrome (eg, autonomic dysregulation, hyperreflexia). (Choice C) Sodium bicarbonate is used to treat cardiac dysrhythmias associated with tricyclic antidepressant (TCA) overdose. TCA overdose can present with somnolence but also is associated with anticholinergic (eg, dry mucous membranes, urinary retention) and cardiovascular (eg, sinus tachycardia) side effects, which are not present in this patient. (Choice E) Serum levels of SSRIs are not readily available in emergency situations and do not correlate with changes in mental status and symptom severity. Educational objective: Isolated overdose of selective serotonin reuptake inhibitors (SSRIs) is usually well tolerated. When a patient with SSRI overdose has altered mental status and abnormal physical examination findings, levels of common coingestants (eg, salicylates, ethanol) should be obtained. References: Paroxetine overdose. (http://www.ncbi.nlm.nih.gov/pubmed/20814462)

An 18-Year-Old Woman Is Brought to the Emergency Department After