Tricyclic antidepressant overdose: Conservative management in a community hospital with cost-saving implications

doi:10.1016/0736-4679(90)90175-U

The Journal of Emergency Medicine

Volume 8, Issue 4, July–August 1990, Pages 451-454

https://doi.org/10.1016/0736-4679(90)90175-U Get rights and content

Abstract

Reports of late-onset cardiovascular complications following tricyclic antidepressant (TCA) overdose have led to a very conservative approach to these patients. Many patients have been hospitalized for continuous cardiac monitoring, regardless of the clinical presentation. Management algorithms based on clinical predictors of outcome have recently been proposed. We used the algorithm developed by Tokarski and Young to retrospectively evaluate the care of 33 TCA overdose patients admitted to our hospital over a 3-year period. We then identified 11 patients who could have been treated on an outpatient basis had the algorithm been employed. Ten were admitted to a monitored unit and spent a mean of 31.6 ± 15.64 hours on the unit. None of the 11 patients developed complications during their hospital stay. Use of the algorithm would have resulted in an estimated cost savings of 13 hospital days and $14,000.

References (16)

G.F. Tokarski et al.
Criteria for admitting patients with tricyclic antidepressant overdose
J Emerg. Med
(1988)
G.E. Foulke et al.
Tricyclic antidepressant overdose: emergency department findings as predictors of clinical course
Am J Emerg Med
(1986)
N.P. Lancaster et al.
Suicidal attempt by imipramine overdosage
Brit Med J
(1959)
A.M. Mann et al.
Toxicity of imipramine: report on serious side effects and massive overdosage
Can Med Assoc J
(1959)
C.M. Steel et al.
Clinical effects and treatment of imipramine and amitriptyline poisoning in children
Brit Med J
(1967)
A.B. Masters
Delayed death in imipramine poisoning
Brit Med J
(1967)
D.G. Spiker et al.
Tricyclic antidepressants: prolonged plasma levels after overdose
JAMA
(1976)
R.J. Goldberg et al.
Cardiac complications following tricyclic antidepressant overdose
JAMA
(1985)

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Cited by (15)

European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
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Citation Excerpt :
Anticholinergic effects include mydriasis, fever, dry skin, delirium, tachycardia, ileus, and urinary retention. Most life-threatening problems occur within the first 6 h after ingestion.301–303 A widening QRS complex (>100 ms) and right axis deviation indicates a greater risk of arrhythmias.304–306
Antidepressant Overdose-induced Seizures
2013, Psychiatric Clinics of North America
Citation Excerpt :
If they remain without signs or symptoms of toxicity, a decision on disposition can be rendered; the patient may require psychiatric evaluation or can be discharged home. Patients who have ingested CAs and who are asymptomatic on presentation, receive activated charcoal, remain asymptomatic for a minimum of 6 hours in the treating facility without any treatment intervention, and have normal ECGs can receive disposition as deemed appropriate.86 Some exceptions that necessitate prolonged monitoring include ingestion of (1) sustained-release formulations, (2) drugs that can cause delayed-onset seizures (eg, bupropion or citalopram), or (3) antidepressants that can cause cardiotoxicity, such as bupropion,85 citalopram and escitalopram,35 or venlafaxine.45
Antidepressant Overdose-induced Seizures
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If they remain without signs or symptoms of toxicity, a decision on disposition can be rendered; the patient may require psychiatric evaluation or can be discharged home. Patients who have ingested CAs and who are asymptomatic on presentation, receive activated charcoal, remain asymptomatic for a minimum of 6 hours in the treating facility without any treatment intervention, and have normal ECGs can receive disposition as deemed appropriate.86 Some exceptions that necessitate prolonged monitoring include ingestion of (1) sustained-release formulations, (2) drugs that can cause delayed-onset seizures (eg, bupropion or citalopram), or (3) antidepressants that can cause cardiotoxicity, such as bupropion,85 citalopram and escitalopram,35 or venlafaxine.45
European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution
2010, Resuscitation
Citation Excerpt :
Anticholinergic effects include mydriasis, fever, dry skin, delirium, tachycardia, ileus, and urinary retention. Most life-threatening problems occur within the first 6 h after ingestion.50–52 A widening QRS complex (>100 ms) and right axis deviation indicates a greater risk of arrhythmias.53–55
Tricyclic antidepressant agents
2005, ECG in Emergency Medicine and Acute Care
ECG abnormalities in tricyclic antidepressant ingestion
1999, American Journal of Emergency Medicine
The tricyclic antidepressant (TCA) agents are recognized for their potentially lethal cardiovascular and neurological effects in poisoned patients. The 12-lead electrocardiogram (ECG) has emerged as a popular bedside tool in the evaluation of TCA toxicity. Although the history and physical examination play a key role in the assessment of the patient with potential TCA poisoning, the presence or absence of features of the TCA toxidrome are not sufficient to detect or exclude toxicity from this class of drugs. A variety of ECG findings occur with TCA toxicity. Aside from the sinus tachycardia due principally to anticholinergic effects, TCA-toxic changes seen on the ECG are attributable primarily to the sodium channel blockade caused by these agents. The majority of patients at significant risk for developing cardiac or neurological toxicity will have a QRS complex greater than 0.10 seconds or a rightward shift of the terminal 40 ms of the frontal plane QRS complex vector. The majority of these patients will also display these changes early in their emergency department stay. However the appearance of these findings, either alone or in combination, does not mean the patient will develop significant cardiac or neurological toxicity. The ECG can neither unequivocally rule in nor rule out impending toxicity; recognizing these limitations, the emergency physician can use this bedside tool in combination with other clinical data during the assessment of the poisoned patient.

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Selected topics toxicologyTricyclic antidepressant overdose: Conservative management in a community hospital with cost-saving implications

Abstract

J Emerg. Med

Am J Emerg Med

Suicidal attempt by imipramine overdosage

Brit Med J

Toxicity of imipramine: report on serious side effects and massive overdosage

Can Med Assoc J

Clinical effects and treatment of imipramine and amitriptyline poisoning in children

Brit Med J

Delayed death in imipramine poisoning

Brit Med J

Tricyclic antidepressants: prolonged plasma levels after overdose

JAMA

Cardiac complications following tricyclic antidepressant overdose

JAMA

Selected topics toxicology
Tricyclic antidepressant overdose: Conservative management in a community hospital with cost-saving implications