Master the board step 3

Master the Boards: USMLE Step 3
A patient with a history of depression comes in with an overdose resulting from
a suicide attempt. There was a bottle of amitriptyline nearby. What is the most
urgent step?
a. Charcoal
b. Gastric lavage
c. Transfer to ICU
d. EKG
e. EEG
f. Head CT
g. Administer bicarbonate
Answer: D. In tricyclic overdose, the most urgent step is to perform an EKG to see if there
is widening of the QRS. Those with a wide QRS are most likely to develop ventricular
tachycardia or torsade de pointes. If there is a wide QRS or an arrhythmia, give bicarbonate
and transfer to the ICU. Gastric lavage is not as important as protecting the
heart. Alkalinizing the patient with bicarbonate carries its own risks. Therefore, finding out
for sure if the patient really needs the bicarbonate is more important.
Other effects of tricyclics are related to their anticholinergic effects:
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Dilated pupils
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Dry mouth
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Constipation
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Urinary retention
Spider Bites
Black Widow
The bite of a black widow spider presents with abdominal pain, rigidity, and
hypocalcemia. The patient presents as though there is a perforated abdominal
organ, but there is pain without tenderness.
Treat with antivenin.
Brown Recluse Spider
The bite of this spider presents with local necrosis, bullae, and dark lesions.
Treat by debriding the wound. Occasionally, steroids and dapsone are of benefit.
Burns
The most important step when a patient has been in a fire is to give 100 percent
oxygen. The most common cause of death in fires is carbon monoxide
poisoning. After that, the most important thing is to determine who needs to
be intubated and who can be managed just with fluids.
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