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Status epilepticus — USMLE Step 3 MCQ

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HardEmergency MedicineStatus epilepticusUSMLE Step 3

A patient is found obtunded beside an empty amitriptyline bottle. Blood pressure is 82/48 mm Hg, QRS duration is 156 ms, and ECG shows a terminal R wave in aVR. What treatment should be given immediately?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Give repeated intravenous sodium bicarbonate boluses guided by QRS duration and perfusion

The best answer is “Give repeated intravenous sodium bicarbonate boluses guided by QRS duration and perfusion”. Amitriptyline causes fast sodium-channel blockade, producing QRS widening, hypotension and ventricular dysrhythmia. Hypertonic sodium bicarbonate supplies sodium and alkalinizes serum; boluses are repeated to clinical and ECG targets. Physostigmine and class IA antiarrhythmics can worsen conduction or provoke seizures.

Reference: AHA Focused Update on Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-and-pediatric-special-circumstances-of-resuscitation