Deliberate self-poisoning with mixed psychotropics (MEQ)

(i) Approach. Airway, breathing and circulation are central to the unknown poisoned patient; after stabilisation, take a systematic approach through history, possible toxidrome, vital signs, examination, laboratory tests, ECG and imaging, then supportive care, decontamination, antidotes and enhanced elimination.^[1]

(ii) Alkalinisation. In TCA poisoning, combined sodium bicarbonate and mechanical ventilation was most effective in achieving serum alkalinisation and was associated with QRS narrowing twice as quickly as single or supportive therapy. The authors advise a maximal bicarbonate dose under 400 mmol (6 mmol/kg).^[2]

(iii) Charcoal. Single-dose activated charcoal should not be given routinely; it may be considered up to one hour after a potentially toxic ingestion of a charcoal-adsorbed poison, and it is contraindicated unless the airway is intact or protected — relevant with a GCS of 11.^[3] Whole bowel irrigation is contraindicated in patients with haemodynamic instability or compromised unprotected airways.^[8]

Flumazenil. Flumazenil carries a risk of seizures, particularly in those who have co-ingested tricyclic antidepressants.^[4]

(iv) Paracetamol. Paracetamol hepatotoxicity is caused by a toxic metabolite normally detoxified by glutathione, and the dose–toxicity relationship led to the Rumack–Matthew nomogram.^[5] Acetylcysteine given within 8 hours was protective regardless of the initial paracetamol concentration, and treatment is still indicated at least as late as 24 hours after ingestion.^[6]

(v) Prescribing. Antidepressants other than TCAs or venlafaxine should be considered in patients at risk of seizure or suicide.^[7]