Tricyclic Antidepressant Toxicity

Perform immediate airway, breathing, and circulation assessment; establish IV access, apply continuous cardiac monitoring, and obtain a 12-lead ECG. Obtain serial ECGs when toxicity is evolving or severe. BMJ+2BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practiceacep[PDF] Acute Amitriptyline Overdose - ACEP

Treat hypoxia, acidemia, and electrolyte abnormalities promptly because cardiovascular complications are managed in part by correcting these reversible amplifiers of sodium-channel blockade. BMJBMJTricyclic antidepressant overdose - Management Approach | BMJ Best Practice In patients with depressed consciousness, seizures, shock, or unstable wide-complex tachycardia, manage in a resuscitation-capable setting while initiating serum alkalinization. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice

For hypotension, begin isotonic crystalloid boluses. If shock persists, use an alpha-adrenergic vasopressor such as norepinephrine or phenylephrine; severe hypotension should not delay sodium bicarbonate when there is QRS widening or other evidence of cardiotoxicity. ScienceDirect+1ScienceDirectReversal of severe tricyclic antidepressant-induced cardiotoxicity with intravenous hypertonic saline solutionScienceDirectTricyclic Antidepressant Overdose - an overview - ScienceDirect.com

In suspected TCA ingestion, obtain an ECG even when the history is incomplete. Typical progression includes sinus tachycardia followed by QRS widening, wide-complex tachycardia, and ventricular arrhythmias as toxicity becomes more severe. BMJBMJTricyclic antidepressant overdose - BMJ Best Practice QRS prolongation is a recognized predictor of subsequent complications, although coma may also identify high-risk patients. BMJBMJTricyclic antidepressant overdose - Management Approach | BMJ Best Practice

Treat a QRS duration greater than 100 ms as actionable cardiotoxicity. Sodium bicarbonate boluses are recommended to narrow the QRS to less than 100 ms, provided serum pH does not exceed 7.55. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice Continue cardiac monitoring during treatment because recurrent clinical or ECG toxicity may require repeated bicarbonate therapy. ScienceDirectScienceDirectTricyclic Antidepressant Overdose - an overview - ScienceDirect.com

Do not use a quantitative amitriptyline concentration to determine acute bedside risk when ECG findings are available. ACEP educational guidance notes that testing may provide only a qualitative TCA screen; management is directed by clinical toxicity, ECG changes, pH, and hemodynamics. acep+1acep[PDF] Tricyclic Antidepressant Overdose - ACEPacep[PDF] Acute Amitriptyline Overdose - ACEP

Give sodium bicarbonate boluses for QRS greater than 100 ms, aiming to narrow the QRS below 100 ms and maintain a maximum pH of 7.50-7.55. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice Bicarbonate is also used when TCA poisoning is complicated by metabolic acidosis, malignant dysrhythmia, hypotension, or cardiac arrest. ScienceDirectScienceDirectTricyclic antidepressant toxicity treated with massive sodium bicarbonate - ScienceDirect

A practical ACEP simulation regimen uses 2-4 ampules of sodium bicarbonate as an initial bolus, followed by an infusion of 150 mEq sodium bicarbonate in 1 L D5W. acepacep[PDF] Tricyclic Antidepressant Overdose - ACEP Reassess the QRS, venous pH, potassium, and other electrolytes after boluses and during infusion; serial ECG, pH, and electrolyte checks every 1-2 hours are recommended in severe acute toxicity. acepacep[PDF] Acute Amitriptyline Overdose - ACEP

Avoid over-alkalinization. When further sodium loading is required but pH approaches the target ceiling, described alternatives include 3% sodium chloride without bicarbonate or modest permissive hypercapnia in a mechanically ventilated patient to permit additional bicarbonate boluses. These strategies require specialist-guided critical-care management. BMJBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice

Treat prolonged seizures with benzodiazepines. ScienceDirectScienceDirectTricyclic Antidepressant Overdose - an overview - ScienceDirect.com Do not administer flumazenil when benzodiazepines may have been coingested, because antagonism can unmask TCA-induced seizures. ScienceDirectScienceDirectTricyclic Antidepressant Overdose - an overview - ScienceDirect.com Seizure, coma, hypotension, and wide-complex tachycardia should each trigger ICU-capable admission and ongoing ECG-directed alkalinization. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice

For ventricular dysrhythmia or wide-complex tachycardia in TCA toxicity, first correct acidemia, hypoxia, electrolyte derangements, and sodium-channel blockade with sodium bicarbonate. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice If major arrhythmia persists despite bicarbonate, management may require antiarrhythmic therapy in addition to bicarbonate under specialist direction. BMJBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice

Do not use intravenous lipid emulsion as a substitute for sodium bicarbonate in hypotensive TCA toxicity: American Heart Association material reports no improvement in hypotension compared with sodium bicarbonate. AHA JournalsAHA JournalsPart 3: Adult Basic and Advanced Life Support: 2020 American ... Hypertonic saline is a rescue option only after hypotension fails to respond to adequate bicarbonate alkalinization and aggressive fluid resuscitation. ScienceDirectScienceDirectTricyclic Antidepressant Overdose - an overview - ScienceDirect.com

Patients with hypotension, wide-complex tachycardia, coma, seizures, or significant anticholinergic toxicity require ICU-level admission after initial stabilization. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practice Continue continuous cardiac monitoring and obtain serial ECGs, venous pH, and electrolytes every 1-2 hours in severe acute toxicity. acepacep[PDF] Acute Amitriptyline Overdose - ACEP

Severe toxicity generally occurs early. Patients who remain free of QRS widening, other conduction abnormalities, altered mental status, seizures, and hypotension during the first 6 hours can be classified as lower risk and no longer require PICU monitoring in the pediatric source; for accidental ingestion of a dose unlikely to be toxic, asymptomatic patients at 6 hours may be monitored at home per out-of-hospital guidance. BMJ+1BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeScienceDirectTricyclic Antidepressant Overdose - an overview - ScienceDirect.com Intentional exposure, uncertain timing, coingestion, or unreliable observation should still drive a more conservative disposition decision.

Before stepping down monitoring after bicarbonate therapy, document sustained QRS normalization, hemodynamic stability, resolution of seizures or altered mental status, and a pH that is not above the recommended 7.50-7.55 ceiling. BMJ+2BMJTricyclic antidepressant overdose - Management Approach | BMJ Best PracticeBMJTricyclic antidepressant overdose - Treatment algorithm | BMJ Best Practiceacep[PDF] Acute Amitriptyline Overdose - ACEP