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Diagnosis and Management of Tricyclic Antidepressant Ingestion

  • Patrick George Minges
  • Robert W. ShafferEmail author
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Abstract

Tricyclic antidepressant (TCA) overdoses have become less common over the last 20 years as their overall use has decreased with the advent of safer and more effective antidepressants. Despite their declining popularity in the management of depression, they continue to be used clinically for conditions including the management of neuropathic and chronic pain, cyclic vomiting, nocturnal enuresis, OCD and ADHD. These medications continue to be a leading cause of mortality from intentional ingestions, and account for nearly half of all antidepressant-related deaths (Yates et al., Semin Dial 27(4):381–389, 2014). Common tricyclic antidepressants in use today include amitriptyline, nortriptyline, imipramine, desipramine and doxepin.

The management of tricyclic antidepressant poisonings can be quite challenging. Since they exert their toxicity through several different mechanisms an understanding of their pharmacology is imperative. TCAs all have inherent anticholinergic effects that may cause tachycardia, altered mental status and seizures. They can cause profound hypotension through alpha-adrenergic blockade as well as catecholamine depletion through reuptake inhibition. Finally, they block fast sodium channels in the cardiac conduction system leading to myocardial depression and ventricular arrhythmias (Agrawal et al., J Emerg Med 34(3):321–325, 2008).

Successful treatment of patients poisoned by tricyclic antidepressants hinges on prompt diagnosis and recognition of the classic EKG findings associated with their toxicity. GI decontamination should be considered when patients present within the first 1–2 h following an overdose. Serum alkalinization with sodium bicarbonate is considered the first-line treatment when signs of cardiotoxicity develop. Patients with refractory hypotension may require vasopressor support.

Keywords

Overdose Toxicology Tricyclic antidepressant Cyclic antidepressant Overdose Sodium bicarbonate Seizure Arrhythmia Ventricular tachycardia QRS interval Hypotension Intralipid Magnesium sulfate Lidocaine Hypertonic saline Amitriptyline Nortriptyline 

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Emergency MedicineUniversity of Michigan HospitalsAnn ArborUSA
  2. 2.Department of Emergency MedicineUniversity of Michigan Health SystemAnn ArborUSA

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