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Diagnosis and Management of Tricyclic Antidepressant Ingestion

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Evidence-Based Critical Care

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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.

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Authors and Affiliations

  1. Department of Emergency Medicine, University of Michigan Hospitals, Ann Arbor, MI, USA

    Patrick George Minges

  2. Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI, USA

    Robert W. Shaffer

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  1. Patrick George Minges
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  2. Robert W. Shaffer
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Correspondence to Robert W. Shaffer .

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Editors and Affiliations

  1. Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan, USA

    Robert C. Hyzy

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Minges, P.G., Shaffer, R.W. (2017). Diagnosis and Management of Tricyclic Antidepressant Ingestion. In: Hyzy, R. (eds) Evidence-Based Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-43341-7_6

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  • DOI: https://doi.org/10.1007/978-3-319-43341-7_6

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-43339-4

  • Online ISBN: 978-3-319-43341-7

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