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Tricyclic Antidepressant Overdose
Poisoning Tricycl Antidepres
Electrocardiogram showing QRS widening in patient with TCA overdose
Presentation
- This guideline presents a summary of the best available evidence to guide the management of adult patients who present to the ED following an overdose of tricyclic antidepressant agents (TCA).[ncbi.nlm.nih.gov]
Entire Body System
Gastric Lavage
- Recovery of cyclic depressants with gastric lavage. J Emerg Med 1989 ; 7 : 373 –7.[doi.org]
- In view of the paucity of evidence that gastric lavage removes a significant amount of drug and the risk of complications associated with the procedure, the routine use of gastric lavage in the management of patients with TCA poisoning is not appropriate[ncbi.nlm.nih.gov]
Fever
- Arrhythmias, including VF and torsade Central nervous system features Drowsiness Coma Seizures Pyramidal signs and rigidity Ophthalmoplegia Anticholinergic features Dry mouth Blurred vision Dilated pupils Urinary retention Ileus, absent bowel sounds High fever[derangedphysiology.com]
- , sudden high fever with jaundice, priapism (condition marked by persistent erections), swollen lymph nodes and respiratory distress.[drugs.nmihi.com]
- A tricyclic overdose may cause: Hallucinations Drowsiness Enlarged pupils Fever Irregular heartbeat Severe dizziness Severe muscle stiffness or weakness Restlessness or agitation Breathing problems, respiratory failure Vomiting Convulsions Coma A TCA[healthyplace.com]
- […] small pupils Hypothermia, bradycardia, respiratory arrest, acute lung injury Airway protection, IPPV naloxone Salicylates Aspirin Altered mental status, respiratory alkalosis, metabolic acidosis, tinnitus, hyperpnoea, tachycardia, sweating Low-grade fever[academic.oup.com]
- Generally anticholinergic effects do not cause serious clinical problems but cases of toxic megacolon and intestinal perforation have been described. 11, 12 By impairing sweating heat dissipation is reduced and this can result in a fever, especially if[doi.org]
Congestive Heart Failure
- In patients who can not tolerate the volume of fluid associated with an infusion (eg, those with congestive heart failure, renal impairment, or end-stage renal disease), use of repeated boluses may be preferable.[emedicine.medscape.com]
- The use of imipramine in depressed patients with congestive heart failure. JAMA 1983 ; 250: 1997 – 2001 [Crossref], [PubMed], [Web of Science ], [Google Scholar] ).[doi.org]
Hypothermia
- Hypertension followed by hypotension RESP: ARDS, aspiration pneumonitis CNS: Seizures, CNS depression, drowsiness, coma, extra pyramidal effects GI/GU: Decreased or absent bowel sounds, urinary retention OTHER: Metabolic acidosis, hyper-/hypothermia Decontamination[calsprogram.org]
- Successful use of therapeutic hypothermia after cardiac arrest due to amitryptiline and venelafaxine intoxication. Ther hypothermia Temp manag. 2015;5(2):104–9. View Article PubMed Google Scholar Eken C.[bmcresnotes.biomedcentral.com]
- , defaecation, muscle weakness, bronchorrhoea Bradycardia, dilated or constricted pupils, seizures, respiratory failure, paralysis Airway protection and IPPV, atropine, pralidoxime Opioid Heroin, morphine CNS and respiratory depression, small pupils Hypothermia[academic.oup.com]
Cardiovascular
Hypotension
- The overall frequency of admission hypotension (systolic BP less than 95 mmHg) was 34% (22 of 64 patients).[ncbi.nlm.nih.gov]
- K Channel Blockade QTC Prolongation NE & Serotonin Reuptake Inhibition Initial hypertension quickly followed by hypotension Na Channel Blockade QRS Prolongation Hypotension — depresses myocardial contractility Ventricular dysrhythmias Brugada-like findings[em3.org.uk]
Tachycardia
- Sinus tachycardia with QRS prolongation may be difficult to distinguish from ventricular tachycardia.[ncbi.nlm.nih.gov]
Hypertension
- K Channel Blockade QTC Prolongation NE & Serotonin Reuptake Inhibition Initial hypertension quickly followed by hypotension Na Channel Blockade QRS Prolongation Hypotension — depresses myocardial contractility Ventricular dysrhythmias Brugada-like findings[em3.org.uk]
- (J Emerg Med 1995;13(6):781-5) This one is from Bryan Hayes) Pharmacologic Effects of TCAs K Channel Blockade QTC Prolongation NE & Serotonin Reuptake Inhibition Initial hypertension quickly followed by hypotension Na Channel Blockade QRS Prolongation[emcrit.org]
- Hypertension followed by hypotension RESP: ARDS, aspiration pneumonitis CNS: Seizures, CNS depression, drowsiness, coma, extra pyramidal effects GI/GU: Decreased or absent bowel sounds, urinary retention OTHER: Metabolic acidosis, hyper-/hypothermia Decontamination[calsprogram.org]
- Amphetamine, Methamphetamine, Cocaine, Diet aids, Nasal decongestants, Bath Salts Stimulant Signs and symptoms Restlessness, Agitation, Incessant talking, insomnia, Anorexia, dilated pupils, tachycardia, tachypnea, hypertension or hypotension, paranoia[quizlet.com]
- Vasodilators are first-line therapy for treating amphetamine-induced hypertension E. Wide-complex tachydysrhythmias should be treated initially with sodium bicarbonate Question 2.[foamcast.org]
Eyes
Blurred Vision
- Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest.[en.wikipedia.org]
- Clinical Effects HEENT: Nystagmus, blurred vision, dry mouth, flushing, mydriasis CV: Widening of the QRS interval is the most commonly used marker of toxicity. A QRS interval 0.1 second is indicative of potential toxicity.[calsprogram.org]
- vision Dilated pupils Urinary retention Ileus, absent bowel sounds High fever, or inability to regulate temperature Anhidrosis Delirium Metabolic features Metabolic acidosis Respiratory acidosis Management of tricyclic overdose Decontamination Activated[derangedphysiology.com]
- Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest. [1] If symptoms have not occurred within six hours of exposure they are unlikely to occur. [2] TCA overdose[ipfs.io]
- […] gastrointestinal distress, diarrhea, respiratory depression, apnea, seizures, coma Anticholinergic Drug Examples Atropine, Scopolamine, Antihistamines, Antipsychotics, Anticholinergic Signs and Symptoms Dry, Flushed skin, hyperthermia, dilated pupils, blurred[quizlet.com]
Neurologic
Seizure
- No seizures or ventricular arrhythmias occurred in Group A. In Group B there was a 34 per cent incidence of seizures and a 14 per cent incidence of ventricular arrhythmias. All patients survived.[doi.org]
- More severe complications include hypotension, cardiac rhythm disturbances, hallucinations, and seizures.[en.wikipedia.org]
- Seizures and aspiration pneumonia may occur regardless of initial BP.[ncbi.nlm.nih.gov]
Confusion
- Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest.[en.wikipedia.org]
- The patient started with a confused mental state and decreased to a GCS of eight, potentially indicating the need for an advanced airway.[ems1.com]
- Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest. [1] If symptoms have not occurred within six hours of exposure they are unlikely to occur. [2] TCA overdose[ipfs.io]
- […] mydriasis agitation and seizures, hyperthermia Sedative/hypnotics Drug Examples Phenobarbital, diazepam AKA Valium, thiopental, midazolam aka versed, lorazepam Sedative/hypnotics Signs and symptoms Drowsiness, disinhibition, ataxia, slurred speech, mental confusion[quizlet.com]
Agitation
- Cardiovascular Tachycardia Hypotension (cause of mortality) Arrhythmia-SVT/VT VT in 4% of cases approx) CNS Ataxia Nystagmus Sedation, coma Seizures (about 5% of cases) Amblyopia Anticholinergic Mydriasis Dry mouth Absent bowel sounds Urinary retention Agitation[emed.ie]
- Initial or mild symptoms typically develop within 2 hours and include tachycardia, drowsiness, a dry mouth, nausea and vomiting, urinary retention, confusion, agitation, and headache.[en.wikipedia.org]
- Labored breathing, low blood pressure, shock, enlarged pupils, coma, agitation, hallucinations, muscle rigidity, convulsions, and agonal breathing were also reported.[aa400415.wordpress.com]
- Amphetamine, Methamphetamine, Cocaine, Diet aids, Nasal decongestants, Bath Salts Stimulant Signs and symptoms Restlessness, Agitation, Incessant talking, insomnia, Anorexia, dilated pupils, tachycardia, tachypnea, hypertension or hypotension, paranoia[quizlet.com]
- GCS was 9 (E2M5V2) although she appeared agitated with bilaterally dilated pupils. There was no external evidence of injury.[icmcasesummaries.com]
Altered Mental Status
- The authors describe a patient with tricyclic antidepressant overdose who presented with altered mental status and whose serial ECG changes played a significant role in diagnosing and predicting the impending cardiovascular toxicity.[ncbi.nlm.nih.gov]
- Serotonin syndrome consists of a triad of altered mental status, neuromuscular hyperactivity, and autonomic instability, similar in presentation to neuroleptic malignant syndrome—hyperpyrexia, acidosis, arrythmias, and rhabdomyolysis are seen.[academic.oup.com]
- A 24-year-old man presents to the ED via the police because of altered mental status and violent behavior. The patient reportedly had been on a drug binge, using amphetamines and cocaine for the last 2 days.[foamcast.org]
Ataxia
- […] on the agent 70% excreted by the kidney Acidosis increases the amount of active drug in plasma by decreasing protein binding Clinical effects Cardiovascular Tachycardia Hypotension (cause of mortality) Arrhythmia-SVT/VT VT in 4% of cases approx) CNS Ataxia[emed.ie]
- […] tachycardia, dilated pupils aka mydriasis agitation and seizures, hyperthermia Sedative/hypnotics Drug Examples Phenobarbital, diazepam AKA Valium, thiopental, midazolam aka versed, lorazepam Sedative/hypnotics Signs and symptoms Drowsiness, disinhibition, ataxia[quizlet.com]
- Clinical manifestations are associated with drowsiness, respiratory depression, dysarthria, and ataxia. Coma is not common but is most often seen in the elderly or patients who have ingested alcohol or other drugs. Treatment is supportive.[academic.oup.com]
- In a prospective, unblinded trial of imipramine's effects on depression in 44 adults, patients receiving 3.5 mg/kg/day in divided doses (mean 245 mg daily in men and 218 mg daily in women) experienced orthostatic hypotension, dizziness, ataxia, and falls[doi.org]
Workup
QRS Wave
Wide QRS Complex
- In those who have a wide QRS complex ( 100 ms) sodium bicarbonate is recommended. If seizures occur benzodiazepines should be given. In those with low blood pressure intravenous fluids and norepinephrine may be used.[en.wikipedia.org]
- In those who have a wide QRS complex ( 100 ms ) sodium bicarbonate is recommended.[ipfs.io]
- There are wide QRS complexes with rapid ventricular rate ( Ventricular tachcardia ): Toxicity Tricyclics have a narrow therapeutic index, i.e. the therapeutic dose is close to the toxic dose.[wikidoc.org]
Rhythm
Torsades De Pointes
- Torsade de pointes occurs uncommonly. Hypotension results from a combination of reduced myocardial contractility and reduced systemic vascular resistance due to alpha-adrenergic blockade.[ncbi.nlm.nih.gov]
- Doxepin-induced torsade de pointes tachycardia. Ann Intern Med 2001; 135: 384–5 PubMed Google Scholar 43. Davison ET. Amitriptyline-induced torsade de pointes: successful therapy with atrial pacing.[doi.org]
- There may also be a ventricular arrythmia, particularly polymorphic ventricular tachycardia, specifically Torsades de Pointes. This should be treated typically with a magnesium sulfate infusion of 2 g over two minutes.[ems1.com]
Other ECG Findings
Electrocardiogram Change
- Serial electrocardiogram changes in acute tricyclic antidepressant overdoses. Crit Care Med 1997; 25: 1721–6 PubMed CrossRef Google Scholar 36. Shannon MW. Duration of QRS disturbances after severe tricyclic antidepressant intoxication.[doi.org]
- Serial electrocardiogram changes in acute tricyclic antidepressant overdoses. Crit Care Med 1997; 25: 1721–6 PubMed CrossRef Google Scholar 11. Shannon MW. Duration of QRS disturbances after severe tricyclic antidepressant intoxication.[dx.doi.org]
- Electrocardiogram changes are common and precede the development of hypotension and neurological deterioration, therefore close watch on ECG monitoring is strongly recommended in the patients of TCAs poisoning. References 1.[mjdrdypu.org]
Treatment
- There is no role for physostigmine in the treatment of tricyclic toxicity as it may increase cardiac toxicity and cause seizures.[en.wikipedia.org]
- Treatment of antidepressant poisoning with resin hemoperfusion. Hum Toxicol 1982; 1: 361–71 PubMed CrossRef Google Scholar 65. Diaz-Buxo JA, Farmer CD, Chandler JT. Hemoperfusion in the treatment of amitriptyline intoxication.[dx.doi.org]
Prognosis
- Prognosis GCS of less than 8 predicts serious complications with a sensitivity of 86% and specificity of 89%. A high GCS does not rule out significant ingestion 24.[slideshare.net]
Etiology
- We reviewed literature pertaining to the etiology, epidemiology, pathophysiology, and management of TCA-induced lung injury, as well as other case reports.[ncbi.nlm.nih.gov]
Epidemiology
- This article reviews epidemiologic, pharmacologic, and therapeutic information to provide a systematic approach to these potentially life-threatening overdoses.[ncbi.nlm.nih.gov]
- The epidemiology of major depression in South Africa: results from the South African stress and health study. S Afr Med J 2009;99:367-373. 3. Tomlinson M, Grimsrud AT, Stein DJ, Williams DR, Myer L.[samj.org.za]
- The epidemiology of poisoning. Medicine, Vol. 35, Issue. 10, p. 537. CrossRef Google Scholar Çaksen, Hüseyin Akbayram, Sinan Odabaş, Dursun Özbek, Hanefi Erol, Mehmet Akgün, Cihangir Tuncer, Oguz and Yilmaz, Cahide 2006.[doi.org]
Sex distribution
Age distribution
Pathophysiology
- We reviewed literature pertaining to the etiology, epidemiology, pathophysiology, and management of TCA-induced lung injury, as well as other case reports.[ncbi.nlm.nih.gov]
- Olson K, Benowitz NL (1984) Environmental and drug-induced hyperthermia: pathophysiology, recognition and management. Emerg Med Clin North Am 2: 459–474 Google Scholar 8.[link.springer.com]
- Pharmacology/Pathophysiology Tricyclic antidepressants (TCAs) exert their effects by a variety of mechanisms.[calsprogram.org]
- […] toxic dose. [7] Factors that increase the risk of toxicity include advancing age, cardiac status, and concomitant use of other drugs. [8] However, serum drug levels are not useful for evaluating risk of arrhythmia or seizure in tricyclic overdose. [9] Pathophysiology[ipfs.io]
- Neuromuscular blockade also can be used along with continuous EEG monitoring for the treatment of refractory seizure to avert life-threatening hyperthermia. 2 Understanding the pathophysiology of TCA overdose and its effect on the cardiovascular system[journals.lww.com]
Prevention
- As in other overdoses, counseling to prevent ingestions is more than worth "a pound of the cure."[ncbi.nlm.nih.gov]
- Administration of 1meq/kg of sodium bicarbonate will bind the medication for excretion to prevent continued or ongoing absorption of the drug.[ems1.com]
- Immediate measures should be taken in this situation, both to decrease absorption of the culprit drug and to prevent and overcome malignant arrhythmias.[innovationsincrm.com]
- Do antidepressants prevent suicide?. International Clinical Psychopharmacology, Vol. 21, Issue. 4, p. 211. CrossRef Google Scholar Dean, Angela J. McDermott, Brett M. and Marshall, Robert T. 2006.[doi.org]