Multiple tablet overdose with multi-organ involvement and critical illness neuropathy: A case report from Kauvery Hospital, Trichy
Johnson A1, Lavanya2, Aarthi3
1Group Clinical Pharmacist, Kauvery Hospital, Trichy, Tamil Nadu
2Clinical Pharmacist, Kauvery Hospital, Trichy, Tamil Nadu
3Clinical Pharmacist Trainee, Kauvery Hospital, Trichy, Tamil Nadu
Abstract
Multiple tablet overdose represents a life-threatening poisoning emergency requiring coordinated multidisciplinary management. This case report documents the clinical course of a 23-year-old female admitted with acute polymedication overdose involving seven different psychotropic and cardiovascular medications. The patient presented with severe respiratory compromise requiring mechanical ventilation, aspiration pneumonia, hemodynamic instability, and subsequent development of critical illness neuropathy. Over a 60-day hospitalization period, intensive management including tracheostomy, supportive care, antimicrobial therapy, and rehabilitation resulted in complete neurological recovery and discharge to home. This case illustrates the importance of early airway management, comprehensive toxicology screening, aggressive supportive care, and prevention of complications in improving outcomes in acute poisoning cases. We present this case to highlight the multifaceted clinical challenges and the successful evidence-based approach that led to favorable outcomes in severe oral polymedication overdose.
Keywords: Multiple tablet overdose; Critical illness neuropathy; Aspiration pneumonia; Intensive care management; Toxicology; Mechanical ventilation
Introduction
Acute poisoning remains a significant global health concern, with World Health Organization estimating approximately 346,000 deaths annually from unintentional poisoning [1]. Multiple tablet overdose (polymedication overdose) represents a particularly challenging subset of poisoning cases due to unpredictable pharmacokinetic interactions, varied clinical presentations, and potential for multiorgan involvement [2]. Psychotropic medications, including antidepressants and antipsychotics, frequently feature in overdose cases and carry considerable risk for central nervous system depression, cardiovascular instability, and seizure activity [3].
The combination of multiple medications in a single ingestion creates a complex clinical scenario where the cumulative effect often exceeds the sum of individual drug toxicities. Complications such as aspiration, respiratory compromise, and secondary infections significantly impact morbidity and mortality [4]. Additionally, the development of critical illness myopathy and neuropathy in survivors of severe poisoning represents an understudied but clinically significant complication that requires prolonged rehabilitation [5].
This case report presents a detailed analysis of a young female with severe multiple tablet overdose who developed multiorgan dysfunction including respiratory failure, aspiration pneumonia, sepsis, and critical illness neuropathy. Over a 60-day hospitalization period, comprehensive intensive care management resulted in complete neurological recovery and successful rehabilitation. The case highlights the importance of early aggressive supportive care, systematic toxicology approach, and multidisciplinary involvement in improving outcomes in severe poisoning cases.
Patient Demographics and History
The 23-year-old female, was brought to Kauvery Hospital, Trichy, on October 14, 2025, at 18 30 hours via emergency medical services. According to accompanying relatives, the patient consumed multiple tablets at approximately 17 30 hours on the same date in a self-harm attempt.
Tablets consumed (confirmed history)
- Opipramol 50 mg (tricyclic antidepressant) – 7 tablets
- Desvelaflaxine (SNRI antidepressant) – unknown quantity
- Clonazepam (benzodiazepine) – unknown quantity
- Quetiapine (atypical antipsychotic) – unknown quantity
- Propranolol (beta-blocker) – unknown quantity
- Bupropion (antidepressant) – unknown quantity
- Dextromethorphan (levorphanol derivative) – unknown quantity
Relevant medical history
- Anxiety neurosis
- Bipolar II disorder
- Bronchial asthma
- Obesity
- Smoking and multiple substance abuse
- Regular treatment under psychiatrist and neurologist
- Known sulpha drug allergy
Social history: The patient had a known psychiatric history with management by specialists. Family history of psychiatric disorders was noted.
Initial Presentation and Emergency Department Assessment
At emergency department arrival (18 30 pm, Day 1), the patient was found to be drowsy, arousable to voice, with irrelevant speech production. Detailed initial assessment revealed
Vital signs at presentation
- Heart rate – 86 beats/minute (regular)
- Blood pressure – 90/60 mmHg
- Respiratory rate – 20 breaths/minute
- SpO₂ – 93-94% on room air
- Glasgow Coma Scale – 11/15 (E3V2M5)
- Temperature – 36.8°C
Physical examination findings
- Drowsy, arousable to voice, oriented to person only
- Bilateral occasional crackles noted on respiratory examination
- Cardiovascular examination revealed tachycardia
- Neurological examination showed depressed reflexes with bilateral occasional crackling sounds
Initial emergency management
At 18: 30 hours, after informed anaesthesia consultation, the patient was administered activated charcoal and basic life support was initiated. Noradrenaline infusion was commenced at 6 ml/hour for hemodynamic support.
Course During Day 1 (October 14, 2025) – 1 00 AM to 2 30 AM
The patient’s condition deteriorated rapidly in the early morning hours
Clinical deterioration
- Vomiting and severe breathing difficulty developed
- Respiratory rate increased to 40-50 breaths/minute
- Oxygen saturation fell to 78-82% (desaturation episodes)
- Patient became restless and irritable
- RR ranged 40-50/min, SpO₂ 78-82%
Interventions
- Oxygen support via nasal cannula was initiated (NIV considered but patient was not cooperative)
- At 02:20 hours, emergency intubation was performed after anaesthesia consultation
- Post-intubation parameters FiO₂ 1.0 (100%), SpO₂ 84%, HR 103, BP falling
- Central venous catheter placement at 03 30 hours
- Femoral arterial line placement for continuous monitoring
- Noradrenaline increased to 10 ml/hour and Fentanyl infusion started
- Patient received 2 units PRBC transfusion at 04 00 hours
- Intravenous albumin infusion initiated
Diagnosis at this stage: Multiple tablet overdose, acute respiratory failure, shock, aspiration or infection pneumonia
Hospital Course – First Two Weeks (Days 2-14)
Days 2-3 (October 15-16)
- Patient received in IMCU 2
- Initial vital signs – HR 88, BP 100/60 (on low-dose Noradrenaline), SpO₂ 94%
- Respiratory rate – 28-30, mild respiratory acidosis
- Clinical presentation – Drowsy, obeying commands, producing irrelevant speech
- Medications initiated Thiopentone sedation, Vecuronium muscle relaxant, Noradrenaline 0.5 ml/hour maintenance, Inj. Meropenem 1gm Started
Days 9-11
- Patient progressed to supine position ventilation
- Oxygen requirements optimized SpO₂ maintained at 95-98%
- FiO₂ reduced to 40%
- Thiopentone continued, paralysis reduced
- Mechanical ventilation showing improvement
- ENT consultation obtained for potential tracheostomy assessment
Days 12-13
- Performed tracheostomy on Day 12
- HR 120, BP 150/90
- SpO₂ 94%, FiO₂ 35%
- Post-tracheostomy management with Thiopentone, Vecuronium, Noradrenaline 0.5 ml/hour
- Colistin and Fluconazole initiated for empirical infection coverage
- Day 13 assessment Similar clinical status with high fever spikes observed
Days 14-18
- Thiopentone discontinued, transitions to supportive care
- No paralysis, reducing sedation burden
- FiO₂ maintained at 35-40%, SpO₂ 94-97%
- Fever spikes noted (Day 16 observations)
- Occasional eye opening observed
- New clinical concerns Tracheal infections evidenced by Acinetobacter in respiratory cultures
- Blood cultures positive for Burkholderia species
- Urine analysis revealed Candida species
Day 17-18 Critical deterioration event
- Patient positioned for optimal ventilation
- Tracheal secretions showed Acinetobacter colonization
- Blood cultures positive for Burkholderia cepacia
- Urine culture positive for Candida
- Left subclavian central venous catheter placement
- Left radial arterial line placement
- Noradrenaline infusion 1 ml/hour
- Additional critical intervention required due to secondary infections
Mid-Phase Hospital Course (Days 19-23)
Days 19-20 (December 1-2)
- Significant improvement in consciousness level
- Patient became conscious enough, oriented to person
- Flickering eye movements noted with spontaneous activity
- Able to follow simple commands
- Albumin infusions continued
- Low-dose Noradrenaline infusion (0.5 ml/hour) for hemodynamic support
- FiO₂ reduced to 35%, SpO₂ maintained at 95-97%
- SIMV mode (Synchronized Intermittent Mandatory Ventilation) used
Day 20 Critical illness neuropathy recognition
- Neurological assessment revealed critical illness neuropathy as emerging complication
- This diagnosis marked transition from acute phase to recovery phase
Days 21-23
- Consciousness improved further
- Patient became conscious and obeying commands
- Hemoglobin improved to 5.8 g/dL
- PRBC transfusion 2 units administered
- Albumin supplementation continued
- Clinical status Conscious, obedient to commands
- Skin care – Skin peeling/redness addressed with topical application
- Plastic surgery consultation obtained
- Hydro-heal treatment initiated for wound care
- Albumin supplementation extended to 4th day
- SIMV and PS (Pressure Support) alternating modes used
- FiO₂ maintained at 35-40%, SpO₂ 98%, HR 108
Recovery Phase (Days 24-40)
Days 24-30
- Afebrile status maintained
- Pressure sore management with Bactigrass dressing
- Overnight SIMV mode (PS and BIPAP alternating)
- Gradual improvement in overall condition
- Day time activities increased
- Meropenem 1gm was stopped.
Day 29 Medical milestone
- Antibiotic course completed
- Steroid tapering was discussed and planned
- Continued pressure sore management
- Overall clinical improvement noted
Day 31 Significant event
- Patient achieved near-arrest recovery status
- Positioned for optimal care
- Desaturation episodes managed (SpO₂ previously 60/40 mmHg)
- Hypotension managed BP 60/40 mmHg initially, improved with intervention
- Atropine administration (20 ml IV 10 ml-6ml) for bradycardia management
- Noradrenaline maintained at 1 ml/hour
- Position changes facilitated recovery
Days 32-39
- BIPAP (Bilevel Positive Airway Pressure) increased hours
- Injection Doxy (Doxycycline) continued
- Tracheostomy tube care and management
- Patient achieving tracheostomy-life status (spontaneous breathing during day, assisted at night)
- Speaking tube trial initiated
- ENT opinion obtained for speaking tube placement
Days 40-51
- Pressure sore care continued
- Motor power gradually improving
- Day 41 Foley catheter removed, patient pain improved
- Meropenem antibiotic reinitiated and continued for 7 days.
- Day 43 Patient under assessment – motor power still reduced
- Blood cultures negative
- Foley catheter placement repeated due to urinary retention concerns
- Temperature maintained at stable levels (occasional spikes addressed)
- Day 47 Peripheral IV catheter removed
- CVC lines were managed and sequentially removed
- Healing bedsore Tracheostomy stoma closure assessment planned
- Continued rehabilitation
Late Recovery Phase and Rehabilitation (Days 52-60)
Day 52
- Patient discharged from ICU to general ward
- Status Shifted to Hamsa (rehabilitation facility within hospital campus)
Days 52-60 (Rehabilitation phase)
- Active physiotherapy initiated
- Motor power showed progressive improvement
- Focused rehabilitation protocol implemented
- Day 60 Discharged to home from Hamsa facility
- Final status Discharged in stable condition with complete motor power recovery
Clinical Complication Management
1. Respiratory Failure and Airway Management
Pathophysiology The patient’s respiratory compromise resulted from multifactorial etiology including direct central nervous system depression from psychotropic agents, aspiration secondary to altered consciousness, and chemical pneumonitis from ingested medications.
Management approach
- Early mechanical ventilation (Day 1, 02 20 hours) prevented further deterioration
- Initial settings FiO₂ 100%, PEEP appropriate for oxygenation
- Progressive FiO₂ reduction (100% → 35-40%) over 3-week period based on clinical improvement
- Tracheostomy performed at Day 12 to facilitate long-term ventilatory support and reduce airway trauma
- Gradual transition from controlled ventilation to SIMV, then PS/BIPAP modes
- Complete weaning achieved by Day 52 with successful discharge
Outcome Successful extubation and independent breathing maintained post-discharge.
2. Aspiration Pneumonia and Secondary Infections
Clinical presentation Lower respiratory tract infection developed by Days 12-14, manifesting with fever, elevated respiratory secretions, and microbiological evidence of infection.
Microbiological findings
- Respiratory cultures Acinetobacter species
- Blood cultures Burkholderia cepacia
- Urine cultures Candida species
- These findings suggested multifocal infection requiring broad-spectrum coverage
Management approach
- Empirical broad-spectrum antibiotics started early (Colistin, Fluconazole)
- Subsequent cultures guided targeted antimicrobial therapy
- Meropenem added to regimen for resistant organism coverage
- Antibiotic course completed by Day 29
- Infection resolution confirmed by negative blood cultures
Outcome Successful infection management without septic shock progression.
3. Hemodynamic Instability and Shock
Clinical course Hypotension developed from admission and persisted through Days 1-31, requiring continuous vasopressor support.
Management strategy
- Noradrenaline initiated at 6 ml/hour (Day 1, 18 30 hours)
- Dose adjustments based on blood pressure response (range 0.5-10 ml/hour)
- Central venous catheterization for accurate hemodynamic monitoring
- Fluid resuscitation with albumin infusions
- PRBC transfusion (2 units) on Days 2 and 21-23
- Progressive vasopressor weaning from Day 31 onwards
- Complete withdrawal by Day 52
Outcome Successful hemodynamic stabilization without requirement for higher-dose vasopressors or additional inotropic agents.
4. Critical Illness Neuropathy (CIN)
Diagnosis and recognition Critical illness neuropathy was diagnosed around Day 20 during neurological reassessment as the patient regained consciousness. This complication manifested as marked motor weakness affecting all limbs despite adequate management of infection and hemodynamic parameters.
Pathophysiology CIN typically develops in critically ill patients as result of prolonged immobilization, sepsis, systemic inflammatory response, and nutritional inadequacy. The exact mechanism remains incompletely understood but involves microvascular dysfunction and axonal damage [6].
Clinical management approach
- Recognition that CIN would require extended rehabilitation rather than acute interventions
- Nutritional optimization during hospitalization (albumin supplementation)
- Planned transition to rehabilitation facility (Day 52)
- Active physiotherapy initiation at Hamsa rehabilitation facility
- Motor power assessment and progressive mobilization
- Day-by-day improvement in motor function observed during rehabilitation phase
Outcome Complete neurological recovery with full motor power restoration by Day 60, enabling discharge to home in stable condition.
5. Pressure Ulcer Prevention and Management
Development Despite early recognition and preventive measures, pressure ulcers developed due to prolonged immobility during mechanical ventilation and sedation.
Management approach
- Bactigrass dressing application (Days 24-30)
- Plastic surgery consultation obtained (Day 21)
- Hydro-heal treatment initiated for wound care
- Regular position changes and pressure relief measures
- Continued dressing care through rehabilitation phase
Outcome Gradual healing of pressure sores with complete wound closure by discharge.
Clinical Summary and Treatment Timeline
Key Treatment Modalities
Pharmacological management
- Vasopressors Noradrenaline (0.5-10 ml/hour depending on phase)
- Antimicrobials Colistin, Fluconazole, Meropenem (broad-spectrum coverage based on cultures)
- Hemodynamic support Albumin infusions, PRBC transfusion
- Supportive medications Thiopentone (sedation), Vecuronium (paralysis during initial phase), Fentanyl, Atropine (for bradycardia)
- Symptomatic management Doxycycline for secondary infection
Procedures and interventions
- Emergency endotracheal intubation (Day 1, 02 20 hours)
- Central venous catheter placement (subclavian, Day 1, 03 30 hours)
- Arterial line placement (femoral, Day 1, 03 30 hours; radial, Day 18)
- Foley catheterization (Days 2-41, re-inserted Day 43)
- Tracheostomy (Day 12)
- Plastic surgery consultation (Day 21)
Monitoring and support modalities
- Continuous cardiac and hemodynamic monitoring
- Sequential SpO₂ monitoring (range 78-98%)
- Mechanical ventilation modes Controlled ventilation → SIMV → PS → BIPAP
- Progressive FiO₂ reduction (100% → 35-40%)
- Regular laboratory assessment including blood cultures, urinalysis, microbiological samples
Factors Contributing to Successful Recovery
Several factors were instrumental in achieving favorable outcome in this challenging case
- Early airway management prompt intubation prevented further respiratory deterioration and aspiration escalation
- Multidisciplinary approach involvement of intensive care specialists, infectious disease team, anesthesiology, surgery, plastic surgery, ENT, and physiotherapy ensured comprehensive management
- Infection prevention and management systematic toxicology approach with broad-spectrum coverage initially, followed by culture-directed targeted therapy prevented sepsis progression
- Aggressive supportive care continuous hemodynamic monitoring, vasopressor titration, nutritional optimization, and early mobilization supported recovery
- Recognition of complications Early identification of critical illness neuropathy allowed appropriate transition to rehabilitation
- Rehabilitation access availability of dedicated rehabilitation facility (Hamsa) within hospital campus ensured continuity of care and intensive physiotherapy
- Family support consistent family involvement and coordination facilitated compliance with rehabilitation protocols
Discussion
Multiple tablet overdose represents a distinct category of acute poisoning with unique challenges requiring tailored management approaches. This case illustrates several important clinical principles
Toxicology and Clinical Manifestation
The seven-drug combination ingested in this case created a complex toxidrome characterized primarily by central nervous system depression and secondary cardiovascular effects. Opipramol (tricyclic antidepressant) contributed anticholinergic effects, propranolol induced bradycardia and hypotension, while benzodiazepines and antipsychotics amplified CNS depression [7]. This synergistic effect resulted in rapid deterioration requiring mechanical ventilation within 4 hours of ingestion.
Respiratory Management in Poisoning Cases
The early intubation decision proved critical in this patient’s management. Delayed intubation in poisoning cases frequently results in aspiration and secondary pneumonia, significantly increasing morbidity [8]. The progressive reduction of FiO₂ requirements from 100% to 35-40% reflected gradual resolution of pulmonary edema and aspiration injury over a 3-week period. Tracheostomy at Day 12 prevented further tracheal trauma and facilitated oral hygiene and suctioning.
Secondary Infection Management
The development of multifocal infection with Acinetobacter, Burkholderia cepacia, and Candida is well-recognized in prolonged ICU stays [9]. Notably, in this case, empirical broad-spectrum therapy was initiated before culture results, which prevented sepsis progression. The sequential culture-directed narrowing of antibiotics thereafter helped reduce antibiotic pressure and allowed complete discontinuation by Day 29. This approach balanced aggressive initial coverage with subsequent de-escalation based on microbiological evidence.
Critical Illness Neuropathy an Often-Overlooked Complication
Critical illness neuropathy develops in 50-70% of critically ill patients experiencing sepsis and multiorgan dysfunction [10]. In this case, CIN became apparent around Day 20 as the patient’s consciousness improved but motor weakness persisted despite adequate management of infection and hemodynamic parameters. The diagnosis was confirmed through neurological examination and clinical criteria. Unlike critical illness myopathy (which involves muscle injury), CIN involves axonal degeneration and requires extended physiotherapy rather than acute medical intervention [11].
The recovery from CIN in this case over a 40-day period (Days 20-60) demonstrates that with appropriate rehabilitation and early mobilization, complete neurological recovery is achievable. This contrasts with previous literature suggesting persistent disability in some CIN cases. The availability of dedicated rehabilitation facility and early physiotherapy initiation likely contributed to favorable neurological outcome.
Prognostic Factors in Severe Poisoning Cases
Several prognostic indicators predicted favorable outcome in this case
- Young age (23 years) Age <40 years associated with better recovery from critical illness
- Absence of pre-existing organ dysfunction patient had no baseline hepatic, renal, or cardiac disease
- Early aggressive supportive care immediate airway management and hemodynamic optimization
- Responsive to treatment evidence of infection resolution, hemodynamic stabilization, and neurological improvement
- Rehabilitation access institutional capacity for extended physiotherapy and monitoring
Comparison with Existing Literature
Published case series of multiple tablet overdose have reported mortality rates ranging from 10–30% in different series [12] [13]. Our patient’s successful recovery represents a favorable outcome, likely attributable to the combination of early management, advanced ICU capabilities, and comprehensive rehabilitation access.
Learning Points for Clinical Practice
This case provides several important teaching points for healthcare professionals
- High index of suspicion for aspiration altered consciousness from any cause predisposes to aspiration, requiring early airway protection and prophylactic broad-spectrum coverage
- Systematic toxicology approach when exact medications ingested are unknown, empirical broad-spectrum therapy should cover major toxidromes while awaiting confirmatory tests
- Recognition of complications critical illness neuropathy and myopathy are frequently overlooked in sedated patients; early recognition during neurological awakening allows timely transition to rehabilitation
- Vasopressor optimization long-term noradrenaline infusions (up to 31 days in this case) require careful titration and gradual weaning, with risk of rebound hypotension
- Infection prevention early mobilization, regular pressure sore care, and prompt removal of invasive lines reduce secondary complications
- Rehabilitation importance access to dedicated rehabilitation facilities and early physiotherapy significantly impacts neurological recovery outcomes
Ethical Considerations
This case involved a patient admitted following a self-harm attempt with underlying psychiatric illness. The care provided respected patient autonomy while providing life-sustaining medical interventions. Involvement of psychiatry team (documented in medical records) ensured appropriate psychological support during and after acute medical management. The successful medical recovery allowed subsequent psychiatric rehabilitation and community reintegration.
Conclusion
This case report documents the successful management of a young female with severe multiple tablet overdose complicated by respiratory failure, aspiration pneumonia, multifocal infection, and critical illness neuropathy. Over a 60-day hospitalization period, comprehensive intensive care management including early intubation, targeted antimicrobial therapy, hemodynamic optimization, and intensive rehabilitation resulted in complete neurological and functional recovery.
The favorable outcome in this challenging case demonstrates the importance of
- Early aggressive supportive care in severe poisoning cases
- Multidisciplinary team approach with involvement of specialists from critical care, infectious diseases, surgery, and rehabilitation
- Proactive complication recognition to enable timely intervention
- Access to rehabilitation facilities for recovery from critical illness neuropathy
- Sustained family and institutional support throughout the recovery journey
As poisoning cases increasingly involve multiple medications with complex pharmacokinetic interactions, recognition of unique clinical challenges and application of evidence-based management strategies are essential for improving outcomes. This case adds to the growing body of literature demonstrating that even severe, life-threatening poisoning cases can result in complete recovery with appropriate comprehensive management.
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