Tricyclic antidepressant overdose

Tricyclic antidepressant overdose should be suspected in patients with a history of depression, suicidality, and overdose presenting with a sudden deterioration in mental status and vital signs.

At 1 to 2 hours after ingestion, there is a rapid decline in mental and cardiovascular status. Diagnosis is established on clinical grounds and classic ECG changes (sinus tachycardia progressing to wide complex tachycardia and ventricular arrhythmias with increasing severity of intoxication).

Hypertonic sodium bicarbonate improves conduction abnormalities and hypotension.

Management of arrhythmias involves correction of acidosis, hypoxia, and electrolyte imbalance. Antiarrhythmic drugs should generally be avoided.

Hypotension usually responds to correction of hypoxia and administration of intravenous fluids and sodium bicarbonate. Treatment with vasopressors is controversial and should only be done in consultation with a medical toxicologist or intensive care specialist.

Benzodiazepines are the first-line treatment for seizures.

An antidepressant overdose occurs when a person ingests an amount of medication that is more than a reasonable and normal dose.[1]Henry JA, Alexander CA, Sener EK. Relative mortality from overdose of antidepressants. BMJ. 1995;310:221-224. http://www.bmj.com/cgi/content/full/310/6974/221 http://www.ncbi.nlm.nih.gov/pubmed/7866123?tool=bestpractice.com Tricyclic antidepressants are the main cause of damaging antidepressant overdose because, unlike other antidepressants, they have a narrow therapeutic range and become potent cardiovascular and central nervous system toxins in moderate doses. Complications include effects of prolonged hypotension, cardiac arrhythmias, and seizure. Death results from cardiovascular collapse.