Antidepressant Toxicity Treatment & Management

  • Author: Jeena Jacob, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Feb 8, 2010
 

Prehospital Care

Closely monitor vital signs and cardiovascular, neurological, and respiratory status in addition to ECG monitoring. Rapidly transport all patients with possible TCA ingestion to the hospital because clinical deterioration often occurs rapidly after overdose. Although the effectiveness of out-of hospital activated charcoal has not been studied in the prehospital setting, because of the aspiration risk involved, it is not routinely recommended. Aggressive airway support is vital. Flumazenil administration is contraindicated following TCA overdose.

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Emergency Department Care

Immediate evaluation is imperative for any patient presenting with a suspected tricyclic overdose. Intravenous access should be obtained, and the patient should be connected to a cardiac monitor. If the patient presents with CNS depression, intubation should be considered. An ECG should be obtained, and basic laboratory studies, including electrolytes and glucose levels, should be sent. If the patient is presenting with altered mental status, an arterial blood gas measurement should be obtained.

  • Dysrhythmias
    • Sodium bicarbonate is the first-line therapy if TCA ingestion is known or strongly suspected. Sodium bicarbonate should be considered in life-threatening circumstances in the prehospital setting if there is a protocol for its use.
    • Procainamide, quinidine, beta-blockers, and calcium channel blockers are contraindicated.
  • Hypotension
    • Hypotension is treated with sodium bicarbonate and intravenous fluids.
    • Animal studies show a benefit to using hypertonic saline to reverse cardiotoxicity, but the doses for TCA poisoning have never been evaluated in humans. One case report describes the successful use of 7.5% NaCl to treat refractory hypotension and QRS widening. This modality could be considered in refractory cases but should not supersede treatment with NaHCO3.
    • Vasopressors are recommended for refractory hypotension.
  • Convulsions
    • Benzodiazepines
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Consultations

  • Consider consulting a regional poison control center or medical toxicologist.
  • Patients with abnormal vital signs or mental status changes will need intensive care unit (ICU) care, which may require the consultation of an intensivist.
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Contributor Information and Disclosures
Author

Jeena Jacob, MD  PharmD, Medical Toxicology Fellow, Rocky Mountain Poison and Drug Center, Denver, CO

Jeena Jacob, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Theodore I Benzer, MD, PhD  Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

David C Lee, MD  Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Eric Legome, MD, and Craig Smollin, MD, to the development and writing of this article.

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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