Tricyclic Antidepressant Overdose Mimicking

A 39 year old female patient with altered mental status wasbrought to the emergency department by basic life sup-port ambulance. A neighbour found her unresponsive in her bed at home with a farewell letter revealing suicidal intention. On arrival the patient was lethargic with a blood pressure of 150/90 mmHg, a pulse rate of 100 beats/min and a respiratory rate of 10/min. The 12-lead ECG (Figure 1, column 1) on admission showed a sinus tachycardia and moderate altera-tions of the QRS complex and altered repolarisation. Urine-drug screening proved to be positive for tricyclic antidepres-sants. For further monitoring and treatment the patient was admitted to the intensive care unit. Because of the patient’s altered mentation she underwent paralysis-assisted endotra-cheal intubation. 14 hours later, a repeat ECG (Fig. 1, col. 2) showed ST tract elevation in leads V1, V2 and aVL with recip-rocal ST depression inferior, QRS widening and slight pro