Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management

Abstract

American Association of Poison Control Centers, Washington, District of Columbia, USAA review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidencebased expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, pal...

Intravenous lipid emulsion therapy for flecainide toxicity

“…In the two cases reported here, one with cardiac arrest and the other with severe cardiogenic shock, toxicity resolved after treatment with ILE therapy. Sodium bicarbonate has demonstrated efficacy in reversing QRS prolongation and cardiotoxicity following overdoses of tricyclic antidepressant [5] and other sodium channel blockers, but it was ineffective in these two cases.…”

Child Abuse: A Complex Case Report: Association of Amitriptyline Intoxication and Shaken Baby Syndrome

“…Concerning amitriptyline intoxication, 50 mg/ kg is the lowest ingestion associated with mild toxicity and 15 mg/kg corresponds to the lowest dose associated with death. A single case of 325 mg (16 mg/kg) nortriptyline ingestion by a 4-year-old resulted in severe toxicity [7]. One fatal case of acute malicious exposure to amitriptyline of a 3-year-old was reported to the Annual report of the American Association of Poison Control Centers in 2002.…”

“…One fatal case of acute malicious exposure to amitriptyline of a 3-year-old was reported to the Annual report of the American Association of Poison Control Centers in 2002. The blood analyses revealed that the dosage of amitriptyline was: 4.600 µg/L and nortriptyline: 2.900 µg/L [7].…”

“…The American association of poison control centers reported 430 cases of amitriptyline intoxication in 2012 [2] and 996 cases of intentional ingestion of amitriptyline in children under 6 years old in 2002 including one fatal case [7].…”

Effect of hypertonic saline on electrocardiography QRS duration in rabbit model of bupivacaine toxicity resuscitated by intravenous lipid

“…Hypertonic sodium solutions are widely accepted as an antidote in systemic poisoning with non local-anaesthetic agents characterised by antagonism of fast-gated sodium ion channels [14,15]. Many psychotropic agents (tricyclic antidepressants for example) frequently taken in overdose share with bupivacaine both sodium channel blockade as a significant component of the toxicity and elevated lipophilicity [16].…”