Tricyclic Antidepressant Toxicity in Pediatrics Clinical Presentation

Updated: Apr 22, 2016
  • Author: Derrick Lung, MD, MPH; Chief Editor: Timothy E Corden, MD  more...
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Presentation

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 (not available in the United States) and amitriptyline have been shown to have greater toxicity than the other cyclic antidepressants. [6]

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.

Next:

Physical Examination

Physical examination findings relate to the anticholinergic, cardiovascular, and central nervous system (CNS) effects of cyclic antidepressants. Anticholinergic effects are typically the first to appear and should raise clinical suspicion of cyclic antidepressant overdose. One suggested aid to help identify and recall severe CA toxicity is the mnemonic "S-A-L-T" (ie, shock, altered mental status, long-QRS interval duration, terminal R wave in aVR). [7]

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 QRS and QT intervals
  • Heart block
  • Peripheral vasodilatation
  • Hypotension
  • Cardiogenic shock
  • Ventricular dysrhythmias
  • Asystole

CNS effects may include the following:

  • Drowsiness
  • Extrapyramidal signs
  • Rigidity
  • Ophthalmoplegia
  • Respiratory depression
  • Delirium
  • Seizure
  • Coma
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