A drowsy 36-year-old female took 20 amitriptyline 150 mg tablets 15 minutes ago. She states she wants to die. What should you do?

• A. Immediately transport her.
• B. Administer syrup of ipecac.
• C. Administer oxygen.
• D. Advise her of the risks and allow her to refuse.

Answer: (A)

In a drowsy patient who has just ingested a very large amount of amitriptyline, the priority is life-saving care and rapid transport to an emergency department for definitive management. Massive tricyclic antidepressant overdose can cause dangerous cardiac conduction disturbances, seizures, hypotension, and coma, so getting her to a facility quickly for monitoring, decontamination, and possible antidotal/supportive treatments is essential.

Syrup of ipecac is not used in modern EMS care because it rarely improves outcomes and increases the risk of aspiration in a drowsy patient. Providing oxygen is helpful if she is hypoxic, but it does not address the overdose itself and should not replace rapid transport. Advising her and letting her refuse is inappropriate here because she is not in a position to make a safe, informed decision given her stupor and the high risk of deterioration; EMS can provide treatment and transport under implied consent in life-threatening emergencies.

On scene, maintain airway and breathing, apply oxygen if indicated, monitor vitals, and rapidly transport to the hospital so she can receive definitive care, including possible charcoal decontamination, cardiac monitoring, and antidotal therapies as needed.