Case 1126 - A Young Woman Presenting to the ED with Tachycardia and Hypotension

Contributed by: Matthew Romanish, DO and Kenichi Tamama, MD, PhD

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 serum alkalinization was not needed. She was safely discharged home after her brief hospital course.

Diagnosis and Discussion