Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose

Body, Richard; Bartram, Tom; Azam, Fawad; Mackway‐Jones, Kevin

doi:10.1136/emj.2010.091553

Cited by 39 publications

(31 citation statements)

References 84 publications

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“…Mainstays of therapy include aggressive supportive care and sodium bicarbonate (BIC)-initiated systemic alkalinization. 1 More recently, intravenous lipid emulsion (ILE) preparations have been forwarded as adjuncts to standard management of TCA toxicity with successful reports of use in animal models 2 and human subjects. 3 Both pharmacokinetic and pharmacodynamic mechanisms have been forwarded to explain the beneficial effects of ILE.…”

mentioning

confidence: 99%

Comparison of Intravenous Lipid Emulsion, Bicarbonate, and Tailored Liposomes in Rabbit Clomipramine Toxicity

Cave

Harvey

Shaw

et al. 2013

Academic Emergency Medicine

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Objectives: Liposome (LIP)-like lipid dispersions have emerged as useful detoxification vehicles in vitro. The authors compare resuscitation with tailored LIPs, 20% intravenous lipid emulsion (ILE), and sodium bicarbonate (BIC), in a rabbit model of clomipramine toxicity.Methods: Sedated, instrumented New Zealand white rabbits underwent clomipramine infusion at 3.2 mg/kg/min to 50% baseline mean arterial pressure (MAP) and then at 1.6 mg/kg/min for 30 minutes. BIC (3 mL/kg 8.4%), ILE (3 mL/kg 20%), or LIP (24 mg/kg) were infused as rescue treatments at toxicity and were repeated at 10 minutes (n = 5 in each group). remains a difficult therapeutic challenge. Mainstays of therapy include aggressive supportive care and sodium bicarbonate (BIC)-initiated systemic alkalinization. 1 More recently, intravenous lipid emulsion (ILE) preparations have been forwarded as adjuncts to standard management of TCA toxicity with successful reports of use in animal models 2 and human subjects. 3 Both pharmacokinetic and pharmacodynamic mechanisms have been forwarded to explain the beneficial effects of ILE. The widely held lipid sink theory is that lipid sequesters certain xenobiotics (such as TCAs) and reduces toxicity by decreasing the free serum concentration of the offending toxin. 4,5 Liposomes are spherical vesicles of phospholipids and effectively sequester amitriptyline and imipramine in vitro. 6,7 Specific advantages afforded by liposomes (LIPs) include increased surface area:volume ratios, the ability to modulate surface charge and internal pH, and the inherent lipid bilayer structure. To date, however, there are limited data on the antidotal efficacy of liposomal formulations in intact animal models.We examined the effect of LIPs in an established animal model of TCA toxicity. Specifically, in this study we compare resuscitation with bicarbonate (BIC), ILE, and LIPs in a previously studied rabbit model of clomipramineinduced shock. METHODS Study DesignThis was a laboratory study of clomipramine-induced cardiotoxicity in a rabbit model. The study was approved by the institutional ethics committee of the

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mentioning

confidence: 99%

Comparison of Intravenous Lipid Emulsion, Bicarbonate, and Tailored Liposomes in Rabbit Clomipramine Toxicity

Cave

Harvey

Shaw

et al. 2013

Academic Emergency Medicine

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“…6 Nöbet varlığında benzodiyazepinler kullanılmalı, fenitoinden kaçınılmalıdır. 7 Sunduğumuz vakada nöbet gelişmeksizin bilinç durum değişikliği ortaya çıkmıştır.…”

Section: Discussionunclassified

“…7 Ortaya çıkabilecek EKG değişikliklerine [QRS süresinde uzama (>100 ms), QTc süresinde uzama (>430 ms) ve aVR derivasyonunda R / S oranının 0.7'den büyük olması) karşı seri EKG çekimi önerilmektedir. 7 TSA ilaçlar mide boşalmasını geciktirdiği için ilk 1 saat ve daha sonrasında aktif kömür verilmesi; EKG'de yukarıdaki bulguların varlığında ve disritmi, nöbet veya sıvıya dirençli hipotansiyon varlığında intravenöz NaHCO 3 infüzyonu ilk sıra tedavilerdir. 7 Son yıllarda plazma değişim tedavisi, intravenöz lipid emülsiyon tedavisi ve hemodiyafiltrasyonun da TSA intoksikasyonunda başarılı sonuçları bildirilmiştir.…”

Section: Discussionunclassified

“…7 TSA ilaçlar mide boşalmasını geciktirdiği için ilk 1 saat ve daha sonrasında aktif kömür verilmesi; EKG'de yukarıdaki bulguların varlığında ve disritmi, nöbet veya sıvıya dirençli hipotansiyon varlığında intravenöz NaHCO 3 infüzyonu ilk sıra tedavilerdir. 7 Son yıllarda plazma değişim tedavisi, intravenöz lipid emülsiyon tedavisi ve hemodiyafiltrasyonun da TSA intoksikasyonunda başarılı sonuçları bildirilmiştir. [8][9][10] Sunduğumuz vakada da mental durum değişikliği, disritmi ve hipotansiyon gelişmesi üzerine hastaya NaHCO 3 infüzyonu başlanmış, yoğun bakımda da plazma değişim tedavisi uygulanmıştır.…”

Section: Discussionunclassified

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Mortal Seyreden Bir Amitriptilin İntoksikasyonu Olgusu

Yoldaş¹,

Güler²,

Güler³

et al. 2014

Ankara Med J

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ÖzetTrisiklik antidepresanların (TCA) aşırı alımı, ciddi ilaç zehirlenmelerinin en sık sebeplerinden biridir. Görece düşük (10 mg / kg) bir dozda amitriptilinin intihar etmek amacıyla içimi sonrası TCA zehirlenmesine bağlı çok şiddetli nörolojik ve kardiyovasküler belirtiler gösteren 20 yaşında bir kadın hastayı sunuyoruz. Gastrik lavaj, aktif kömür, sistemik alkalinizasyon (pH 7.50 olacak şekilde), destek tedavi ve plazma değişim tedavileri hasta için yeterli olmadı. Hastanın derin koma durumu ve şok tablosu devam etti ve herhangi bir önlem hastayı hayatta tutmaya yetmedi. Bu vaka, TCA zehirlenmesinin önemini ve bu zehirlenmenin düşük dozlarda dahi ölümcül olabileceğini vurgulamaktadır. Anahtar Kelimeler: Amitriptilin, aşırı dozda ilaç alımı, zehirlenme, intihar Abstract Tricyclic antidepressant (TCA) overdose is one of the most common causes of serious drug poisonings. We here report a case with neurologic and cardiovascular manifestations of TCA intoxication following self-poisoning with amitriptyline in a relatively low dose of 10 mg/kg, in a 20-year-old female. Management with gastric lavage, activated charcoal, systemic alkalinization (pH 7.50), supportive care and plasma exchange therapy were not enough for the patient. Deep coma and shock persisted and no measures were enough to keep the patient alive. This case focuses on the importance of TCA intoxication and emphasizes that it can be fatal even at relatively low doses.

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“…We report a case in which severe toxicity was overcome with rapid implementation of supportive measures, and adherence to basic treatment principles (ie, Guidelines in Emergency Medicine Network (GEMNet) guidelines) 6. This case is of specific value because the time of ingestion was well established.…”

Section: Introductionmentioning

confidence: 99%

Rapid diagnosis and treatment of severe tricyclic antidepressant toxicity

2015

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A woman in her mid-50s contacted her social worker and expressed intent to commit suicide by ingesting prescription medications. On arrival of emergency responders, the patient was found unconscious with an empty bottle of amitriptyline. Time of ingestion was estimated using the social worker's contact with local authorities. The patient's presentation at the emergency department (ED) exemplified tricyclic antidepressant toxidrome with a poor prognosis, based on measurable criteria and physical findings. Respiratory and cardiovascular collapse was managed emergently. Haemodynamic status and EKG findings responded in a stepwise fashion with therapy in the ED and intensive care unit. Full clinical recovery took 7 days, and the patient was subsequently transferred to an in-patient psychiatric facility for further evaluation. Eight days later, she was discharged home with no neurological sequelae.

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Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose

Cited by 39 publications

References 84 publications

Comparison of Intravenous Lipid Emulsion, Bicarbonate, and Tailored Liposomes in Rabbit Clomipramine Toxicity

Comparison of Intravenous Lipid Emulsion, Bicarbonate, and Tailored Liposomes in Rabbit Clomipramine Toxicity

Mortal Seyreden Bir Amitriptilin İntoksikasyonu Olgusu

Rapid diagnosis and treatment of severe tricyclic antidepressant toxicity

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