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"Overdose" AND ("Tricyclic Antidepressant" OR "TCA") AND "Sodium Bicarbonate" AND "QRS"

Thamer Kassim, Toufik Mahfood Haddad, Amandeep Rakhra, Amjad Kabach, Ahmad Qurie, Mohammad Selim, Ali S Nayfeh, Ahmed Aly, Mark J Holmberg
Amitriptyline is a widely prescribed tricyclic antidepressant (TCA) with a very concerning cardiotoxicity profile, but it is one that has not been discussed much in literature. Here, we present a case of amitriptyline toxicity presenting as myocarditis with pericardial involvement. A 21-year-old male with no previous cardiac history presented to the emergency department (ED) with a decreased level of consciousness after an amitriptyline overdose as a suicidal attempt. For concerns with airway protection, the patient was intubated and subsequently admitted to the intensive care unit (ICU)...
June 19, 2018: Curēus
Benjamin Ramasubbu, David James, Andrew Scurr, Euan A Sandilands
A 28-year-old woman was admitted in a comatose state following ingestion of 5 g of amitriptyline. On arrival, there was intermittent seizure activity and a broad complex tachycardia on the ECG. Immediate resuscitation included 8 mg lorazepam, 2 L crystalloid fluid, 100 mL 8.4% sodium bicarbonate, 2 g of magnesium sulphate and lipid emulsion infusion. Despite this, the broad complex tachycardia persisted with haemodynamic instability. The case was discussed with the National Poisons Information Service, which advised further 8...
April 11, 2016: BMJ Case Reports
Shawn M Varney, Vikhyat S Bebarta, Toni E Vargas, Susan Boudreau, Maria Castaneda
OBJECTIVES: Tricyclic antidepressants (TCAs) are highly lipophilic medications used to treat posttraumatic stress disorder and chronic pain. Intravenous lipid emulsion (ILE) is a recent antidote for lipophilic drug overdose with unclear effectiveness. ILE has been studied in TCA overdose in small animals, and cases are reported in humans, but controlled studies in a larger animal model are lacking. Given the high lipophilicity of amitriptyline, a TCA, the hypothesis was that ILE would be more effective than the standard antidote sodium bicarbonate in improving amitriptyline-induced hypotension...
November 2014: Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
Karolina Zapalska-Pozarowska, Jarosław Szponar, Michał Tchórz, Halina Kostek, Wojciech Pozarowski
Long QT syndrome is a disease characterized by periodic or constant prolongation of QT interval and attacks of ventricular polymorphic tachycardia known as torsade de pointes. It may appear as a result of various medicines application, both anti-arrhythmic and non-cardiovascular. Currently, a list of medicines which may cause proarrhythmic action in consequence of QT prolongation is long and constantly updated. It contains tricyclic antidepressants, which are the most toxic antidepressants currently used and are often the cause of poisoning and hospitalization on toxicology wards...
2012: Przegla̧d Lekarski
Vikhyat S Bebarta, Joseph Maddry, Douglas J Borys, David L Morgan
BACKGROUND: The cyclobenzaprine structure is similar to amitriptyline; however, tricyclic antidepressant (TCA)-like wide complex dysrhythmia has not been reported. Our objective was to determine the incidence of TCA-like effects in cyclobenzaprine overdoses as reported to 6 poison centers for 2 years. We compared the incidence of these effects to amitriptyline overdoses collected during the same period. METHODS: We performed a retrospective review of 2 years of cases as reported to the Texas Poison Center Network...
July 2011: American Journal of Emergency Medicine
Brandon K Wills, Michele Zell-Kanter, Steven E Aks
We describe a case of bupropion-associated QRS prolongation that was unresponsive to intravenous bolus therapy of sodium bicarbonate. Bupropion may cause seizures and conduction delays similar to tricyclic antidepressants in the overdose setting by an unknown mechanism.
March 2009: American Journal of Therapeutics
Alan D Woolf, Andrew R Erdman, Lewis S Nelson, E Martin Caravati, Daniel J Cobaugh, Lisa L Booze, Paul M Wax, Anthony S Manoguerra, Elizabeth J Scharman, Kent R Olson, Peter A Chyka, Gwenn Christianson, William G Troutman
A 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 evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher...
2007: Clinical Toxicology
Martyn Harvey, Grant Cave
STUDY OBJECTIVE: Previous investigators have demonstrated amelioration of lipid-soluble drug toxidromes with infusion of lipid emulsions. Clomipramine is a lipid-soluble tricyclic antidepressant with significant cardiovascular depressant activity in human overdose. We compare resuscitation with Intralipid versus sodium bicarbonate in a rabbit model of clomipramine toxicity. METHODS: Thirty sedated and mechanically ventilated New Zealand White rabbits were infused with clomipramine at 320 mg/kg per hour...
February 2007: Annals of Emergency Medicine
C Tan, S Pillai, P G Manning
A 25-year-old man was brought to the emergency room after being found unconscious. Electrocardiography (ECG) showed changes classical of tricyclic antidepressant (TCA) poisoning. These included sinus tachycardia, QTc prolongation, QRS complex widening, right axis deviation and positive R waves in lead aVR. This unique ECG highlights the importance of lead aVR, which often tends to be ignored. Treatment is started based on ECG findings.
August 2006: Singapore Medical Journal
Niall O'Connor, Shaun Greene, Paul Dargan, Duncan Wyncoll, Alison Jones
BACKGROUND: Tricyclic antidepressant poisoning is often associated with significant cardiovascular and central nervous system toxicity. Effective treatment includes the use of appropriate gastric decontamination techniques, the administration of sodium bicarbonate, and meticulous supportive care. Tricylcic antidepressant toxicity typically lasts 24-48 hours following a significant overdose. CASE REPORT: We describe a case of tricyclic antidepressant poisoning where significant clinical toxicity (QRS prolongation, metabolic acidosis) was observed for up to 4 days following ingestion of a modified-release preparation of amitriptyline...
2006: Clinical Toxicology
Wilma E Monteban-Kooistra, Maarten P van den Berg, Jaap E Tulleken, Jack J M Ligtenberg, John H J M Meertens, Jan G Zijlstra
OBJECTIVE: The Brugada syndrome is a clinical and electrocardiographic familial entity, which may lead to sudden cardiac death. A Brugada pattern ECG may occasionally be caused by conditions such as an overdose of tricyclic antidepressants (TCA). Toxicity of TCA frequently results in the need for critical care support. We retrospectively studied characteristics and electrocardiographic indicators of toxicity of all TCA poisoned patients. SETTING: All patients admitted from 1/1/2000 to 1/11/2004 to our ICU after an act of deliberate self-poisoning were included...
February 2006: Intensive Care Medicine
Jim Miller
Depression is a physiological disorder that is medically treated by increasing the bodily amount of one or all of the following neurotransmitters: serotonin, dopamine and norepinephrine. Although there are seven distinct classes of antidepressants, prehospital care professionals should at minimum be able to distinguish the monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and newer antidepressants that are none of these. Monoamine oxidase inhibitors have severe, potentially life-threatening interactions with a variety of medications, including the paramedic drug meperidine, as well as with many common foods...
October 2004: Emergency Medical Services
J Glauser
Tricyclic antidepressant poisoning causes predictable electrocardiographic abnormalities and can be lethal. Cardiac arrhythmias, hypotension, seizures, and coma are common. Sodium bicarbonate is still considered the treatment of choice for severe toxicity, although a variety of supportive measures may be taken. Hypertonic saline appears to be a promising alternative. A QRS interval longer than 100 ms appears to be a better predictor of serious complications than is an elevated serum tricyclic antidepressant level...
October 2000: Cleveland Clinic Journal of Medicine
R A Harrigan, W J Brady
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...
July 1999: American Journal of Emergency Medicine
E L Liebelt, A Ulrich, P D Francis, A Woolf
OBJECTIVES: To describe the changes over time of the QRS interval and terminal 40-msec QRS frontal axis (T40-ms) in patients with acute tricyclic antidepressant poisoning, to identify clinical factors and treatment associated with these changes, and to determine if patients with tricyclic antidepressant-related complications (seizures and/or arrhythmias) had differences in such serial electrocardiogram (ECG) changes when compared with patients without complications. DESIGN: Prospective, observational, cohort study...
October 1997: Critical Care Medicine
W Wananukul, D E Keyler, P R Pentel
BACKGROUND: Hypotension is a major contributor to mortality in tricyclic antidepressant overdose. Recent data suggest that tricyclic antidepressants inhibit calcium influx in some tissues. This study addressed the potential role of calcium channel blockade in tricyclic antidepressant-induced hypotension. METHODS: Two interventions were studied that have been shown previously to improve blood pressure with calcium channel blocker overdose. CaCl2 and 4-aminopyridine...
1996: Journal of Toxicology. Clinical Toxicology
P R Pentel, W Scarlett, C A Ross, J Landon, A Sidki, D E Keyler
STUDY OBJECTIVE: Tricyclic antidepressants (TCAs) are a leading cause of death from intentional drug overdose. Available therapies are often unsatisfactory. In this study we evaluated the use of a high-affinity drug-specific polyclonal Fab fragment (TFab) as an antidote to desipramine toxicity. DESIGN: We gave anaesthetized rats under mechanical ventilation IV desipramine so that we might study the effect of TFab on survival or IP desipramine to facilitate study of the interaction of TFab and hypertonic sodium bicarbonate (NaHCO3), the standard clinical treatment for TCA overdose...
September 1995: Annals of Emergency Medicine
R K Smith, K O'Mara
Overdose from tricyclic antidepressants (TCAs) is increasing. TCAs are well absorbed orally, highly protein bound, and highly lipid soluble. Clinical features of poisoning with TCAs occur within 12 hours of ingestion, usually after a dose of 20 mg/kg or more. Clinical symptomatology involves various anticholinergic, central nervous system, and cardiovascular effects. Cardiovascular toxicity accounts for the majority of the fatalities and may include a hyperdynamic response, various arrhythmias and heart blocks, or severe hypotension...
August 1982: Journal of Family Practice
P Pentel, N Benowitz
Alkalinization of the blood by administration of sodium bicarbonate or hyperventilation is widely recommended for treatment of cardiac toxicity due to tricyclic antidepressant overdose, yet its efficacy and mechanism of action are poorly defined. We studied the effects and possible mechanism of action of 1 M NaHCO3 on desipramine (DMI) toxicity in anesthetized, paralyzed rats. Administration of DMI (45 mg/kg i.p.) produced a mean increase in QRS duration of 142% and a mean decrease in mean arterial pressure of 46%...
July 1984: Journal of Pharmacology and Experimental Therapeutics
P R Pentel, N L Benowitz
Deaths from tricyclic antidepressant (TCA) overdose are usually due to arrhythmias and/or hypotension. Tricyclic antidepressant toxicity is due mainly to the quinidine-like actions of these drugs on cardiac tissues. Slowing of phase 0 depolarisation of the action potential results in slowing of conduction through the His-Purkinje system and myocardium. Slowed impulse conduction is responsible for QRS prolongation and atrioventricular block, and contributes to ventricular arrhythmias and hypotension. Therapies that improve conduction, e...
March 1986: Medical Toxicology
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