Podcast 98 – Cyclic (Tricyclic) Antidepressant Overdose - a podcast by Scott D. Weingart, MD FCCM
from 2013-05-14T21:44:44
I had a crazy case of Tricyclic Overdose while on an overnight shift at Janus General.
Initial and Post-Treatment EKGs
Initial
Post-Treatment
List of Tricyclic Agents from Wikipedia.org
* Amitriptyline (Tryptomer, Elavil)
* Amitriptylinoxide (Amioxid, Ambivalon, Equilibrin)
* Butriptyline (Evadyne)
* Clomipramine (Anafranil)
* Demexiptiline (Deparon, Tinoran)
* Desipramine (Norpramin, Pertofrane)
* Dibenzepin (Noveril, Victoril)
* Dimetacrine (Istonil, Istonyl, Miroistonil)
* Dosulepin/Dothiepin (Prothiaden)
* Doxepin (Adapin, Sinequan)
* Imipramine (Tofranil, Janimine, Praminil)
* Imipraminoxide (Imiprex, Elepsin)
* Lofepramine (Lomont, Gamanil)
* Melitracen (Deanxit, Dixeran, Melixeran, Trausabun)
* Metapramine (Timaxel)
* Nitroxazepine (Sintamil)
* Nortriptyline (Pamelor, Aventyl, Norpress)
* Noxiptiline (Agedal, Elronon, Nogedal)
* Pipofezine (Azafen/Azaphen)
* Propizepine (Depressin, Vagran)
* Protriptyline (Vivactil)
* Quinupramine (Kevopril, Kinupril, Adeprim, Quinuprine)
Additionally...
* Amineptine (Survector, Maneon, Directim) Norepinephrine-dopamine reuptake inhibitor
* Iprindole (Prondol, Galatur, Tetran) 5-HT2 receptor antagonist
* Opipramol (Insidon, Pramolan, Ensidon, Oprimol) ? receptor agonist
* Tianeptine (Stablon, Coaxil, Tatinol) Selective serotonin reuptake enhancer
* Trimipramine (Surmontil) 5-HT2 receptor antagonist and moderate-potency norepinephrine reuptake inhibitor.
And of course, the non-TCA agents...
* Diphenhydramine
* Cocaine
* Cyclobenzaprine (I add this one to the list, b/c there can be TCA-like effects in toxicity, but it seems the potential for cardiac effects is markedly less though still possible. (J Emerg Med 1995;13(6):781-5) This one is from Bryan Hayes)
Pharmacologic Effects of TCAs
K+ Channel Blockade
QTC Prolongation
NE & Serotonin Reuptake Inhibition
Initial hypertension quickly followed by hypotension
Na+ Channel Blockade
QRS Prolongation
Hypotension — depresses myocardial contractility
Ventricular dysrhythmias
Brugada-like findings on EKG
Muscarinic Anticholinergic Receptor Antagonism
Anticholinergic Toxidrome
Antihistaminergic
CNS stimulation or sedation
Alpha1 Adrenergic Antagonism
Hypotension
GABA-A Receptor Blockade
Seizures
This chart was taken from the excellent Resus Review Blog by Charles Bruen
Sodium Bicarbonate
Increases amount of drug in non-ionized form and may decrease binding to Na-channels [cite]11482860[/cite]
May need many, many amps. For some reason the sodium and the bicarb don't rise significantly in severe toxicity
My goals are QRS duration <100, hemodynamically stable, Na ~150, pH ~7.5
Electrolyte Abnormalities
Beware of hypokalemia and hypocalcemia
Send VBG with lytes at least Q1 hour
Hyperventilation
To promote alkalosis
Hypertonic Saline
If the patient is too alkalotic or out of amps of Bicarb
Further episodes of EMCrit Podcast
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Website of Scott D. Weingart, MD FCCM