Antidepressant Toxicity Treatment & Management

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


Emergency Department Care

Immediate evaluation is imperative for any patient presenting with a suspected tricyclic antidepressant (TCA) 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. Seizures are treated with benzodiazepines.


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 is treated with sodium bicarbonate and intravenous fluids. Vasopressors are recommended for refractory hypotension.

Hypertonic saline 3% can be administered to reverse cardiotoxicity in patients not responsive to sodium bicarbonate. This modality could be considered in refractory cases but should not supersede treatment with NaHCO3.



See the list below:

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