Deliberate self-poisoning with mixed psychotropics (MEQ)

(i) Resuscitation and investigations. ABCDE: protect airway if GCS falls further or aspiration risk rises; oxygen; IV access; continuous monitoring. Check glucose. Obtain ECG (already wide QRS), blood gas, U and E, LFTs, coags, timed paracetamol level, pregnancy test if applicable. Early ICU/toxicology involvement for TCA cardiotoxicity and mixed sedative load. Do not prioritise a long psychiatric interview before medical stabilisation.[1][6]

(ii) TCA cardiotoxicity. Fast Na-channel blockade slows conduction → QRS widening, ventricular arrhythmias, seizures, hypotension (with anticholinergic/alpha-block features). Give IV sodium bicarbonate for wide QRS/arrhythmia/severe acidaemia per local protocol; reassess QRS; benzodiazepines for seizures; avoid Na-channel blocking antiarrhythmics. Specialist consideration of lipid emulsion if refractory life-threatening toxicity.[1][2]

(iii) Decontamination and flumazenil. Activated charcoal only if timing still favourable, toxin is charcoal-bound, and airway is protected — not at the expense of resuscitation; risk of aspiration if unprotected.[3] Do not give routine flumazenil here: mixed OD with TCA, risk of seizures and unmasking of pro-convulsant toxicity; chronic benzo use also increases withdrawal/seizure risk. Supportive care for sedative component.[4]

(iv) Paracetamol. Treat as possible co-ingestion until a timed paracetamol concentration and local nomogram/protocol say otherwise; start N-acetylcysteine when indicated without waiting for late enzyme failure. Early NAC is highly effective; delayed presentations change risk framing.[5]

(v) Psychiatry after clearance. Structured suicide risk assessment (intent, planning, stockpiling, protective factors, substance use, bipolar context). Means restriction: remove remaining stock, supervised dispensing, consider safer antidepressant choices given relative toxicity of TCAs, involve partner with consent, least-restrictive safe disposition (admit if high ongoing risk/capacity concerns under mental health law). Arrange follow-up and crisis plan.[6]