Chemical structure of the tricyclic antidepressant amitriptyline
Specialty
Emergency medicine
Symptoms
Elevated body temperature, large pupils, irregular heart beat, seizures[1]
Usual onset
Within 6 hours[2]
Causes
Accidental or purposeful[2][3]
Treatment
Supportive, sodium bicarbonate, lipid emulsion[2]
Frequency
Relatively common[1][4]
Deaths
270 per year (UK)[1]
Tricyclic antidepressant overdose is poisoning caused by excessive medication of the tricyclic antidepressant (TCA) type. Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest.[1] If symptoms have not occurred within six hours of exposure they are unlikely to occur.[2]
TCA overdose may occur by accident or purposefully in an attempt to cause death.[2] The toxic dose depends on the specific TCA.[2] Most are non-toxic at less than 5 mg/kg except for desipramine, nortriptyline, and trimipramine, which are generally non-toxic at less than 2.5 mg/kg.[5][2] In small children one or two pills can be fatal.[6] An electrocardiogram (ECG) should be included in the assessment when there is concern of an overdose.[2]
In overdose activated charcoal is often recommended.[1] People should not be forced to vomit.[2] In those who have a wide QRS complex (> 100 ms) sodium bicarbonate is recommended.[2] If seizures occur benzodiazepines should be given.[2] In those with low blood pressure intravenous fluids and norepinephrine may be used.[1] The use of intravenous lipid emulsion may also be tried.[3]
In the early 2000s, TCAs were one of the most common causes of poisoning.[1] In the United States in 2004 there were more than 12,000 cases.[2] In the United Kingdom they resulted in about 270 deaths a year.[1] An overdose from TCAs was first reported in 1959.[1]
^ abcdefghiKerr G, McGuffie A, Wilkie S (2001). "Tricyclic antidepressant overdose: a review". Emerg Med J. 18 (4): 236–41. doi:10.1136/emj.18.4.236. PMC 1725608. PMID 11435353.
^ abcdefghijklWoolf AD, Erdman AR, Nelson LS, Caravati EM, Cobaugh DJ, Booze LL, Wax PM, Manoguerra AS, Scharman EJ, Olson KR, Chyka PA, Christianson G, Troutman WG, American Association of Poison Control Centers (1 January 2007). "Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management". Clinical Toxicology. 45 (3): 203–233. doi:10.1080/15563650701226192. ISSN 1556-3650. PMID 17453872. S2CID 27172531.
^ abCao D, Heard K, Foran M, Koyfman A (1 March 2015). "Intravenous lipid emulsion in the emergency department: a systematic review of recent literature". The Journal of Emergency Medicine. 48 (3): 387–397. doi:10.1016/j.jemermed.2014.10.009. ISSN 0736-4679. PMID 25534900.
^Cite error: The named reference Tha2005 was invoked but never defined (see the help page).
^Bartram T (1 March 2008). "Best BETs from the Manchester Royal Infirmary. Bet 3. Toxic levels of tricyclic drugs in accidental overdose". Emergency Medicine Journal. 25 (3): 166–167. doi:10.1136/emj.2007.056788. ISSN 1472-0213. PMID 18299371. S2CID 22419961.
^Rosenbaum T, Kou M (2005). "Are one or two dangerous? Tricyclic antidepressant exposure in toddlers". J Emerg Med. 28 (2): 169–74. doi:10.1016/j.jemermed.2004.08.018. PMID 15707813.
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