eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Tricyclic Antidepressant: Follow-up

Author: Samara Soghoian, MD, MA, Clinical Assistant Professor of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center
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; Frank A Maffei, MD, FAAP, Associate Professor of Pediatrics, Temple University School of Medicine; Director of Medical Student Affairs, Geisinger Health System; Pediatric Critical Care Attending Physician, Janet Weis Children's Hospital at Geisinger Medical Center; Heidi Connolly, MD, Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center
Contributor Information and Disclosures

Updated: Oct 22, 2009

Follow-up

Further Inpatient Care

  • Patients with severe CNS toxicity or any cardiotoxicity should be admitted to an ICU setting. Patients should be monitored for at least 24 hours after the ECG findings normalize and alkalinization therapy is stopped.
  • All patients with suspected or confirmed cyclic antidepressant (CA) overdose should be admitted for cardiac monitoring for at least 12-24 hours. Patients may be admitted to a non-ICU ward for telemetry monitoring if they have persistent signs of mild-to-moderate anticholinergic toxicity (ie, resting tachycardia, mydriasis, behavioral changes, hyperthermia) without serious CNS or cardiac manifestations.
  • Patients with suspected overdose should be screened for suicidal behavior and admitted to a psychiatric facility, if indicated, once they are medically cleared.
  • Children with unintentional overdose should be admitted if inadequate supervision in the home is suspected or if adequate follow-up cannot be assured.

Further Outpatient Care

  • Patients may be discharged from the emergency department (ED) if the ingestion was unintentional, if no signs or symptoms of cyclic antidepressant toxicity are evident during a minimum observation of 6-8 hours, if the parents are reliable, and if appropriate follow-up is assured.

Transfer

  • All serious pediatric cyclic antidepressant overdoses should be admitted to a pediatric ICU. Transfer may be indicated after the patient has been stabilized if the treating hospital has no such facility.

Deterrence/Prevention

  • Prevention remains the first line of defense against all pediatric ingestions. Important prevention measures include child-resistant packaging of all medications, proper storage of medications in the home, education of parents and children as to the risks and proper use of medications, and easy access to poison control center information.

Prognosis

  • Approximately 70% of intentional cyclic antidepressant overdoses may be fatal prior to arrival in the ED. However, among patients who present for medical treatment, serious complications are rare compared with the total number of toxic ingestions, and in-hospital mortality is as low as 2-3%. With early recognition and aggressive treatment, a good outcome can be expected.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to anticipate a rapid deterioration in a patient with cyclic antidepressant (CA) poisoning
  • Failure to intubate an unstable patient or to manage the airway properly during decontamination
  • Failure to recognize anticholinergic symptoms or a newly onset ventricular arrhythmia as signs of cyclic antidepressant poisoning
  • Failure to administer sodium bicarbonate in a timely fashion
 


More on Toxicity, Tricyclic Antidepressant

Overview: Toxicity, Tricyclic Antidepressant
Differential Diagnoses & Workup: Toxicity, Tricyclic Antidepressant
Treatment & Medication: Toxicity, Tricyclic Antidepressant
Follow-up: Toxicity, Tricyclic Antidepressant
Multimedia: Toxicity, Tricyclic Antidepressant
References
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References

  1. Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2005;23(5):589-666. [Medline].

  2. Alonso A, Garcia Rodriguez LA, Logroscino G, et al. Use of antidepressants and the risk of Parkinson's disease: a prospective study. J Neurol Neurosurg Psychiatry. 2009;80:671-675. [Medline].

  3. D'Agostino ML, Risser J, Robinson-Bostom L. Imipramine-induced hyperpigmentation: a case report and review of the literature. Journal of Cutaneous Pathology. 2008;36:799-803. [Medline].

  4. Rosenberg LB, Whang W, Shimbo D, et al. Exposure to tricyclic antidepressants is associated with an increased risk of incident CHD events in a population-based study. International Journal of Cardiology. 2009;epub ahead of print:[Medline].

  5. Kwadijk-de Gijsel S, Bijl MJ, Visser LE, et al. Variation in the CYP2D6 gene is associated with a lower serum sodium concentration in patients on antidepressants. British Journal of Clinical Pharmacology. 2009;68:221-225. [Medline].

  6. Lester L, McLaughlin S. SALT: a case for the sodium channel blockade toxidrome and the mnemonic SALT. Ann Emerg Med. Feb 2008;51(2):214. [Medline].

  7. Bailey B, Buckley NA, Amre DK. A meta-analysis of prognostic indicators to predict seizures, arrhythmias or death after tricyclic antidepressant overdose. J Toxicol Clin Toxicol. 2004;42(6):877-88. [Medline].

  8. Liebelt EL, Ulrich A, Francis PD, Woolf A. Serial electrocardiogram changes in acute tricyclic antidepressant overdoses. Crit Care Med. Oct 1997;25(10):1721-6. [Medline].

  9. Liebelt EL, Francis PD, Woolf AD. ECG lead aVR versus QRS interval in predicting seizures and arrhythmias in acute tricyclic antidepressant toxicity. Ann Emerg Med. Aug 1995;26(2):195-201. [Medline].

  10. Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med. Jun 1985;14(6):562-7. [Medline].

  11. Heard K, Dart RC, Bogdan G, et al. A preliminary study of tricyclic antidepressant (TCA) ovine FAB for TCA toxicity. Clin Toxicol (Phila). 2006;44(3):275-81. [Medline].

  12. Banks CJ, Furyk JS. Review article: Hypertonic saline use in the emergency department. Emerg Med Australas. May 6 2008;[Medline].

  13. Algren DA, Sutter ME. Treatment of tricyclic antidepressant cardiac toxicity. Pediatr Emerg Care. Mar 2008;24(3):199. [Medline].

  14. Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med. Aug 22 1985;313(8):474-9. [Medline].

  15. Callaham M, Kassel D. Epidemiology of fatal tricyclic antidepressant ingestion: implications for management. Ann Emerg Med. Jan 1985;14(1):1-9. [Medline].

  16. Chyka PA, Seger D. Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):721-41. [Medline].

  17. Ellenhorn MJ. Ellenhorn's Medical Toxicology. 2nd ed. Baltimore, MD: Williams & Wilkins; 1997:624-36.

  18. Farrar HC, James LP. Characteristics of pediatric admissions for cyclic antidepressant poisoning. Am J Emerg Med. Sep 1999;17(5):495-6. [Medline].

  19. Weisman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfrank's Toxicologic Emergencies. 6th ed. McGraw-Hill Professional; 1998:925-33.

  20. Goodwin DA, Lally KP, Null DM Jr. Extracorporeal membrane oxygenation support for cardiac dysfunction from tricyclic antidepressant overdose. Crit Care Med. Apr 1993;21(4):625-7. [Medline].

  21. James LP, Kearns GL. Cyclic antidepressant toxicity in children and adolescents. J Clin Pharmacol. Apr 1995;35(4):343-50. [Medline].

  22. Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J. Jul 2001;18(4):236-41. [Medline].

  23. Liebelt EL, DeAngelis CD. Evolving trends and treatment advances in pediatric poisoning. JAMA. Sep 22-29 1999;282(12):1113-5. [Medline].

  24. Liebelt EL, Shanon M. Targeted management strategies for cardiovascular toxicity from tricyclic antidepressant overdose: the pivotal role for alkalinization and sodium loading. Pediatr Emerg Care. Aug 1998;14(4):293-8. [Medline].

  25. Newton EH, Shih RD, Hoffman RS. Cyclic antidepressant overdose: a review of current management strategies. Am J Emerg Med. May 1994;12(3):376-9. [Medline].

  26. Pentel PR, Keyler DE. Clinical Management of Poisoning and Drug Overdose. 3rd ed. Philadelphia, PA: WB Saunders Co; 1998:437-49.

  27. Pimentel L, Trommer L. Cyclic antidepressant overdoses. A review. Emerg Med Clin North Am. May 1994;12(2):533-47. [Medline].

  28. Reith D, Fountain J, Tilyard M, McDowell R. Antidepressant poisoning deaths in New Zealand for 2001. N Z Med J. Oct 24 2003;116(1184):U646. [Medline].

  29. Teba L, Schiebel F, Dedhia HV, Lazzell VA. Beneficial effect of norepinephrine in the treatment of circulatory shock caused by tricyclic antidepressant overdose. Am J Emerg Med. Nov 1988;6(6):566-8. [Medline].

  30. Tenenbein M. Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):753-62. [Medline].

  31. Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):711-9. [Medline].

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Further Reading

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Keywords

cyclic antidepressant, cyclic antidepressant toxicity, CA toxicity, CA overdose, CA poisoning, CA, tricyclic antidepressant toxicity, TCA, TCA overdose, TCA toxicity, TCA poisoning, antidepressant overdose, antidepressant toxicity, antidepressant poisoning

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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 A Maffei, MD, FAAP, Associate Professor of Pediatrics, Temple University School of Medicine; Director of Medical Student Affairs, Geisinger Health System; Pediatric Critical Care Attending Physician, Janet Weis Children's Hospital at Geisinger Medical Center
Frank A 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; 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.

Medical Editor

Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine
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

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

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.

 
 
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