Antidepressant Toxicity Clinical Presentation

Updated: Apr 12, 2015
  • Author: Jeena Jacob, MD, PharmD; Chief Editor: Asim Tarabar, MD  more...
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Presentation

History

Clinical symptoms of antidepressant toxicity often progress rapidly and unpredictably, and many times, patients present asymptomatically or minimally symptomatic and progress to life-threatening cardiovascular and neurologic toxicity within an hour.

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Physical

Central nervous system (CNS) findings are as follows:

  • Early manifestations include altered mental status, psychotic behavior, delirium and agitation (from anticholinergic effect), and hallucinations. These symptoms can later proceed rapidly to lethargy, stupor, and coma.

  • Seizures are usually generalized and often occur within 1-2 hours of ingestion. Seizures occurs in 4% of patients with overdose and in 13% of fatal cases. CNS depression and seizures result from mixed effects including those of neuronal fast sodium channel blockade; reuptake inhibition of monoaminergic neurotransmitters; and blockade of H1-histamine, muscarinic, GABA, and NMDA-glutamate receptors.

  • Other findings include ileus; urinary retention; hyperthermia; and dry, flushed skin from anticholinergic effect.

Cardiac findings are as follows:

  • Hypotension as a result of dysrhythmias or alpha-adrenergic blockade with a possible, lesser role played by cardiac conduction abnormalities and direct myocardial depression, autonomic neuron neurotransmitter depletion (caused by reuptake blockade), and capillary leakage

  • Dysrhythmias

  • Conduction block

  • Slowed ventricular conduction and resulting dysrhythmias from blockade of fast sodium channels

  • Tachycardia caused by muscarinic anticholinergic effects

  • Hypertension (early) caused by inhibition of norepinephrine reuptake

Pulmonary findings are as follows:

  • Acute lung injury

  • Hypoventilation

  • Aspiration pneumonitis secondary to CNS depression

  • Acute respiratory distress syndrome (ARDS)

  • Hypoxia caused by hypoventilation, aspiration, and capillary leakage

Anticholinergic findings are as follows:

  • Tachycardia

  • Hypothermia

  • Agitation (early)

  • CNS depression

  • Mydriasis

  • Dry skin and/or mucous membranes

  • Hyperthermia

  • Decreased gastric motility/ileus

  • Urinary retention

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Causes

Tricyclic antidepressant toxicity can be caused by either an acute ingestion or a chronic ingestion. Toxicity secondary to chronic ingestions usually presents with symptomatology that is an exaggeration of the usual side effects of tricyclics.

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