Tricyclic Antidepressant Toxicity in Pediatrics Clinical Presentation

  • Author: Samara Soghoian, MD, MA; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Mar 25, 2010
 

History

The history in patients with cyclic antidepressant (CA) poisoning may include either intentional or unintentional ingestion. Older children should be screened for suicidal ideation and prior self-harm.

  • An attempt should be made to determine the specific agent ingested because the toxic profiles of different cyclic antidepressants may vary. For example, amoxapine is associated with a higher incidence of seizures, whereas maprotiline is more likely to be cardiotoxic. Both dothiepin and amitriptyline have been shown to have greater toxicity than the other cyclic antidepressants.
  • Patients and their families should be questioned as to the dose and time of ingestion. Onset of symptoms typically occurs within 2 hours, and major complications typically occur within the first 6 hours after exposure.
  • Determine if any co-ingestions have occurred.
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Physical

Physical examination findings relate to the anticholinergic, cardiovascular, and CNS effects of cyclic antidepressants. Anticholinergic effects are typically the first to appear and should raise clinical suspicion of cyclic antidepressant overdose. Recently, a sodium channel blockade toxidrome has been proposed and described, using the mnemonic "S-A-L-T" (ie, shock, altered mental status, long-QRS interval duration, terminal R wave in aVR).[6]

  • Anticholinergic effects may include the following:
    • Xerostomia
    • Blurred vision, mydriasis
    • Urinary retention
    • Hypoactive or absent bowel sounds
    • Pyrexia
    • Myoclonic twitching
  • Cardiovascular effects may include the following:
    • Sinus tachycardia
    • Prolonged PR, QRS, and QT intervals
    • Heart block
    • Peripheral vasodilatation
    • Hypotension
    • Cardiogenic shock
    • Ventricular arrhythmias
    • Asystole
  • CNS effects may include the following:
    • Drowsiness
    • Extrapyramidal signs
    • Rigidity
    • Ophthalmoplegia
    • Respiratory depression
    • Delirium
    • Seizure
    • Coma
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Contributor Information and Disclosures
Author

Samara Soghoian, MD, MA  Clinical Assistant Professor of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center

Samara Soghoian, MD, MA is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FACEP, FAAEM  Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Frank Anthony Maffei, MD, FAAP  Associate Professor of Pediatrics, Temple University School of Medicine; Medical Director, Pediatric Intensive Care Unit, Janet Weis Children's Hospital at Geisinger Health System

Frank Anthony Maffei, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Heidi Connolly, MD  Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael E Mullins, MD  Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Paul D Petry, DO, FACOP, FAAP  Consulting Staff, Freeman Pediatric Care, Freeman Health System

Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

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Toxicity, antidepressant. ECG shows the terminal R wave in aVR and the widened QRS complex associated with tricyclic antidepressant (TCA) toxicity.
 
 
 
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