1. Dosing By Body Weight?

2. Ms KB n 29 yr female n Generalised seizure 1st episode n Presented to local GP run hospital

3. History n Tonic clonic seizure witnessed by partner n Self terminated after < 10 minutes n Ambulance transfer to local hospital n On arrival agitated, settled following IV diazepam

4. Past history n Fibromyalgia n Sjogren’s Syndrome n Meningococcal meningitis 1994 n Depression n Morbid Obesity

5. Medications n Amitriptyline 50 mg QID n Panadeine Forte q 6 h n No Known Drug Allergies

6. Background History n 3/52 dizzy spells, falls, difficulty in sentence formation n 1/52 poor balance, intermittent blurred vision n In bed for previous 48 hours n Fell as attempting to walk to lounge, hit head, generalised seizure, non responsive for 10 minutes

7. Initial Examination n BP 135/85 mmHg, Pulse 85, 100% sat on RA n GCS 12, irrational and aggressive but no focal neurological signs n CVS, Resp, Abdo unremarkable

8. Investigations n ECG sinus tachy 95 bpm, QRS 140 ms

9. Treatment n Diazepam 10 mg IV n Oxygen n Transferred by road to DGH

10. At DGH n Alert and cooperative n BP 138/77 mmHg, pulse 101 n Examination unremarkable n ECG @ 12.40 shows QRS of 120 ms n Commenced on cardiac monitoring n Head CT arranged

11. Subsequent events n Cardiac Arrest 1345 h in toilet n Found in asystole n Cardiac output restored @1405 n Given NaHCO 3 n Retrieval to Newcastle Mater ICU

12. Mater ICU n Pulse 80 BP 140/80 mmHg n Aspiration R LL n GCS 5 n Asystolic arrest due to amitriptyline, probable hypoxic brain injury

13. Mater ICU n Medications as taken –Amitriptyline 200 mg QID –Panadeine Forte 4 tabs q 6 h –For 5 months duration n Asystolic arrest due to amitriptyline, probable hypoxic brain injury

14. Subsequent History n 3 days later remains intubated, eye open to voice, purposeless limb movements, does not obey commands n Extubated on day 13, sent to ward, feeding by NGT n Referral to rehab n Day 27, following one stage commands, commenced oral feeding

15. Outcome n Day 32 discharged to rehab n Hypoxic brain injury n Discharged home to care of husband

16. Chronic TCA poisoning