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Gepubliceerd in: Netherlands Heart Journal 3/2017

Open Access 26-10-2016 | Rhythm Puzzle - Answer

Typical ECG findings in an unconscious patient

Auteurs: R. Joustra, F. N. Polderman, J. L. Smeets, M. C. Daniëls, M. Boulaksil

Gepubliceerd in: Netherlands Heart Journal | Uitgave 3/2017

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Answer

Notably, the ECG on admission shows a Brugada-like electrocardiographic pattern (with right bundle branch block and typical ST-segment elevations in leads V1–V3 with a terminal negative T wave). This Brugada-like pattern is called coved type or type 1 (Fig. 1).
In individuals with a normal baseline ECG, this pattern can be provoked by controlled infusion of sodium channel blocking agents for the diagnosis of Brugada syndrome [1]. However, intoxication with a sodium channel blocking agent may give rise to a transient Brugada-like pattern without an underlying Brugada syndrome.
In patients with a psychiatric history, one should consider involvement of a tricyclic antidepressant (TCA), since TCAs are known to result in sodium channel blockade [2]. Our patient turned out to be using nortriptyline, a TCA, amongst other non-tricyclic antidepressants. Therefore, the suspicion of an intoxication with this drug was raised [3]. Indeed, blood tests showed toxic levels of nortriptyline (507 µg/l (therapeutic levels: 50–150 µg/l; toxic levels: >500 µg/l), E‑10-OH-nortriptyline 386 µg/l).
She was admitted to the intensive care unit and treatment with activated charcoal was started to reduce enteral absorption. Furthermore, she was alkalinised with sodium bicarbonate infusion in order to increase binding of nortriptyline to serum proteins. On follow-up, the ECG abnormalities eventually dissolved (Fig. 2).

Conclusion

Type 1 Brugada-like ECG pattern provoked by TCA intoxication.

Conflict of interest

R. Joustra, F.N. Polderman, J.L. Smeets, M.C. Daniëls and M. Boulaksil declare that they have no competing interest.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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Literatuur
1.
go back to reference Antzelevitch C, Brugada P, Borggrefe M, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111:659–70. CrossRefPubMed Antzelevitch C, Brugada P, Borggrefe M, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111:659–70. CrossRefPubMed
2.
go back to reference Meert A, Vermeersch N, Beckers R, Hoste W, Brugada P, Hubloue I. Brugada-like ECG pattern induced by tricyclic antidepressants. Eur J Emerg Med. 2010;17:325–7. CrossRefPubMed Meert A, Vermeersch N, Beckers R, Hoste W, Brugada P, Hubloue I. Brugada-like ECG pattern induced by tricyclic antidepressants. Eur J Emerg Med. 2010;17:325–7. CrossRefPubMed
3.
go back to reference Tada H, Sticherling C, Oral H, Morady F. Brugada syndrome mimicked by tricyclic antidepressant overdose. J Cardiovasc Electrophysiol. 2001;12:275. CrossRefPubMed Tada H, Sticherling C, Oral H, Morady F. Brugada syndrome mimicked by tricyclic antidepressant overdose. J Cardiovasc Electrophysiol. 2001;12:275. CrossRefPubMed
Metagegevens
Titel
Typical ECG findings in an unconscious patient
Auteurs
R. Joustra
F. N. Polderman
J. L. Smeets
M. C. Daniëls
M. Boulaksil
Publicatiedatum
26-10-2016
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 3/2017
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-016-0910-y