A 30-year-old female with a past medical history significant for WPW and a psychiatric history of major depressive disorder, posttraumatic stress disorder, borderline personality disorder, and several suicide attempts presented to the Emergency Department (ED) with complaints of decreased energy, swollen lymph nodes, weight loss (approximately 13.5 kg), and mild abdominal pain. Subsequent interviews revealed that while waiting for the results of her evaluation, the patient overdosed on 1200 mg of trazodone, 1200 mg of quetiapine, and 900 mg of venlafaxine, as a suicide attempt. Two hours postoverdose, the patient began to exhibit a prolonged QTc interval of 486 ms which contrasted with her QTc baseline of 445 ms (Figure 1). Of note, no delta wave was appreciated in the EKG. Her PR interval was 160 ms at baseline and 146 ms 2 hrs after (Table 1). Baseline blood pressure was noted at 114/70, but 2 hours postoverdose, the patient developed hypotension of 86/45 mmHg. In addition, the patient complained of palpitations with a heart rate ranging from 83 to 97. All psychiatric medications were discontinued, and intravenous fluids were provided. Forty-eight hours after discontinuation of her medication, the patient's EKG normalized including her QTc interval (QT/QTc of 414/434) (Figure 1), and her PR interval was at 160 ms (Table 1). At this point, the patient was medically cleared and transferred to our inpatient unit.
On the inpatient unit, the patient was slowly reintroduced to her psychiatric medications. On day 1, the patient was started on quetiapine 100 mg at bedtime, trazodone 100 mg at bedtime, and venlafaxine 150 mg in the morning. This was gradually raised to a maximum dose of quetiapine100 mg in am and 300 mg at bedtime. Venlafaxine was increased to 225 mg daily and trazodone remained at 100 mg at bedtime. Apart from mild sedation, the patient reported no symptoms or side effects from medications such as sensation of rapid, fluttering, or pounding heartbeats (palpitations); dizziness or lightheadedness; or shortness of breath. The patient was discharged after 11 days of inpatient psychiatric treatment.
After discharge, maintenance treatment consisted of 300 mg of quetiapine, 100 mg of trazodone, and 225 mg of venlafaxine. A year later, the patient was seen in the ED for chest palpitations, pain, and dizziness. Her initial EKG was significant for heart rate of 109 beats per minute, QTc of 450 ms, and PR interval of 160 ms. Twenty-four hours later her EKG showed a QTc interval of 457 ms, PR interval of 170 ms, and heart rate of 89 bpm (Figure 1). Of note, delta waves were not appreciated on either EKG. Initially, the patient was worked up for chest pain via 3 sets of troponins, EKG, and stress test. All test results came back negative. Her symptoms resolved within 24 hours with no changes in medication, and the patient was discharged without further issues.