#MedStudentTwitter : Anyone want to take a stab at this case? 24 yo history of seizures on multiple antiepileptic drugs and psych drugs found after a questionable OD in status epilepticus. Intermittent sz with postictal periods but never returning to baseline before sz again

Patient is given 50 mg of valium in titratable doses over 1-2 hours but intermitant seizures persists. She also has mild hypotension.

What is your next immediate action after being given the ECG?

As @SteelhealsM eluded to, there is a prolonged QRS, which is the main reason to get an ECG on any OD. This can cause hypotension and cardiac depression, and can quickly cause the patient to decompensate. It requires immediate action to reverse the cardiac instability.

So the patient is given 2 amps of Na Bicarb followed by a bicarb gtt (3 amps in d5w at 200cc/hr). Her qrs closes and totally normalizes within minutes and the hypotension resolves. Her seizures are decreased, but still ongoing. Now what?

As @kaygeebee17 pointed out, after failure of benzos, we went straight to intubation. Normally you would give another antiepileptic in your status pathway, but the QRS widening and antiepileptic toxicity took that off the table. So we intubated.

After intubation, since the hypotension resolved with the bicarb, we tried propofol first, which is a great antiepileptic in status, but it still couldn't control the seizures. As @SamirBeso_ rightly pointed out, the last step in status is, in fact a pentobarb coma.

Worked like a charm. Pt went to the ICU and did just fine. Saw her several years later for a completely unrelated complaint.

Why this case is important:
1. Had we not gotten the ECG, you'd continue on the status path and potentially exposed her to more drugs that would have made her cardiac instability worse.

2. All tox cases should get an ECG for this reason. A wide QRS in the setting of an ingestion is potentially lethal if not treated.

3. Not all prolonged QRS in tox is TCA. Benadryl, cocaine, seizure meds, anti-dysrithmics, etc. You have to look for it, recognize it, and treat it.

4. Also important, bc this ECG will 100% be on your boards someday for all you aspiring EM docs out there.