Critical Care and Shock

“Complete” loss of brain stem reflexes – not always brain death! Beware of amitriptyline overdose

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We present a case of “complete” loss of brain stem reflexes following amitriptyline overdose, which mimicked brain death. This case highlights the complexities associated with clinical brain death determination and calls for close attention to details.

Based on previously published case reports, we analyse the relationship with the amitriptyline dose, blood level and timing of neurological recovery. Ours is the fourth case report in literature demonstrating “complete” loss of brain stem reflexes following amitriptyline overdose.

The amount of amitriptyline ingested in these cases (including our case report) ranged from 500 mg to 9 g; the blood concentrations ranged from 1.35 microgram/ml to 3.43 microgram/ml. The neurological recovery seems to start by day two to four with complete neurological recovery by day five to seven.