Guidelines in Emergency Medicine Network (GEMNet): Guideline for the management of tricyclic antidepressant overdose

Emergency Medicine Journal

Volumn 28, Issue 4, 2011, Pages 347-368

  Body, Richard ^a   Bartram, Tom ^a   Azam, Fawad ^a   Mackway Jones, Kevin ^a  

^a MANCHESTER ROYAL INFIRMARY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ACETYLCYSTEINE; ACTIVATED CARBON; ADRENALIN; AMINOPHYLLINE; AMITRIPTYLINE; BENZODIAZEPINE; BICARBONATE; CATECHOLAMINE; CHLORPROMAZINE; DESIPRAMINE; DIAZEPAM; DOBUTAMINE; DOPAMINE; DOXEPIN; EPHEDRINE; GLUCAGON; HYPERTENSIVE FACTOR; IMIPRAMINE; INFUSION FLUID; INTRALIPID; ISOPRENALINE; MAGNESIUM CITRATE; MAGNESIUM SULFATE; NORADRENALIN; NORDAZEPAM; NORTRIPTYLINE; PARACETAMOL; PHENYTOIN; TEMAZEPAM; TRICYCLIC ANTIDEPRESSANT AGENT;

ASPIRATION PNEUMONIA; BLOOD GAS; CARDIOVERSION; DEATH; DEFIBRILLATION; DRUG EFFICACY; DRUG HALF LIFE; DRUG MEGADOSE; DRUG OVERDOSE; DRUG SAFETY; ELECTRIC ACTIVITY; ELECTROCARDIOGRAPHY; EMERGENCY WARD; EVIDENCE BASED EMERGENCY MEDICINE; FLUID RESUSCITATION; GLASGOW COMA SCALE; HEART ARREST; HEART ARRHYTHMIA; HEART OUTPUT; HEART RHYTHM; HEART VENTRICLE FIBRILLATION; HEART VENTRICLE TACHYCARDIA; HUMAN; HYPOTENSION; LENGTH OF STAY; LOW DRUG DOSE; MEAN ARTERIAL PRESSURE; MEDICAL PRACTICE; NONHUMAN; OXYGEN SATURATION; PRACTICE GUIDELINE; PRIORITY JOURNAL; RETURN OF SPONTANEOUS CIRCULATION; REVIEW; SEIZURE; SIDE EFFECT; SINGLE DRUG DOSE; SINUS RHYTHM; SINUS TACHYCARDIA; STOMACH LAVAGE; SURVIVAL RATE; SYSTEMIC VASCULAR RESISTANCE; SYSTOLIC BLOOD PRESSURE; TREATMENT RESPONSE;

ADULT; ANTIDEPRESSIVE AGENTS, TRICYCLIC; EMERGENCY MEDICINE; EMERGENCY TREATMENT; GREAT BRITAIN; HUMANS; OVERDOSE;

EID: 79953227734     PISSN: 14720205     EISSN: 14720213     Source Type: Journal    
DOI: 10.1136/emj.2010.091553     Document Type: Review

References (102)

1. National Institute for Clinical Excellence. Guideline development methods: information for National Collaborating Centres and guideline developers. Updated 2005 edn. London: National Institute for Clinical Excellence, 2004.
2. National Collaborating Centre for Mental Health. Depression: Management of depression in primary and secondary care. National Institute of Clinical Excellence London, 2004. http://guidance.nice.org.uk/page.aspx?o=236667.
3. Kerr GW, McGuffie AC. Tricyclic antidepressant overdose: a review. Emerg Med J 2001;18:236-41. (Pubitemid 34070918)
4. Henry JA, Alexander CA, Sener EK. Relative mortality from overdose of antidepressants. Br Med J 1995;310:221-4.
5. National Statistics. The controller of HMSO. 2008. http://www.statistics. gov.uk.
6. Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J 2001;18:236-41. (Pubitemid 34070918)
7. Brennan FJ. Electrophysiological effects of imipramine and doxepin on normal and depressed cardiac Purkinje fibers. Am J Cardiol 1980;46:599-606. (Pubitemid 10009813)
8. Shannon M, Merola J, Lovejoy FH. Hypotension in severe tricyclic antidepressant overdose. Am J Emerg Med 1988;6:439-42.
9. Thorstrand C. Clinical features in poisonings by tricyclic antidepressants with special reference to the ECG. Acta Med Scand 1976;199:337-44.
10. Marshall JB, Forker AD. Cardiovascular effects of tricyclic antidepressant drugs: therapeutic usage, overdose, and management of complications. Am Heart J 1982;103:401-14. (Pubitemid 12178725)
11. Taylor DJE, Braithwaite RA. Cardiac effects of tricyclic antidepressant medication: a preliminary study of nortriptyline. Br Heart J 1978;40:1005-9. (Pubitemid 9036590)
12. Hantson P, Benaissa M, Clemessy J, et al. Hyperthermia complicating tricyclic antidepressant overdose. Intensive Care Med 1996;22:453-5. (Pubitemid 26174320)
13. Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J 2001;18:236-41. (Pubitemid 34070918)
14. McMahon AJ. Amitriptyline overdose complicated by intestinal pseudo-obstruction and caecal perforation. Postgrad Med J 1989;65:948-9. (Pubitemid 20013666)
15. Ross JP, Small TR, Lepage PA. Imipramine overdose complicated by toxic megacolon. Am Surg 1998;64:242-4. (Pubitemid 28246479)
16. Roberge RJ, Martin TG, Hodgman M, et al. Acute chemical pancreatitis associated with a tricyclic antidepressant (clomipramine) overdose. J Toxicol Clin Toxicol 1994;32:425-9. (Pubitemid 24269366)
17. Callaham M, Kassel D. Epidemiology of fatal tricyclic antidepressant poisoning: implications for management. Ann Emerg Med 1985;14:1-9. (Pubitemid 15161256)
18. Lipper B, Bell A, Gaynor B. Recurrent hypotension immediately after seizures in nortriptyline overdose. Am J Emerg Med 1994;12:452-3. (Pubitemid 24215784)
19. Starkey IR, Lawson AAH. Poisoning with tricyclic and related antidepressants - a ten year review. Q J Med 1980;49:33-49. (Pubitemid 10039099)
20. Taboulet P, Michard F, Muszynski J, et al. Cardiovascular repercussions of seizures during cyclic antidepressant poisoning. J Toxicol Clin Toxicol 1995;33:205-11.
21. Miadinich EK, Carlow TJ. Total gaze paresis in amitriptyline overdose. Neurology 1977;27:695.
22. Smith MS. Amitriptyline ophthalmoplegia. Ann Intern Med 1979;91:793. (Pubitemid 10190008)
23. Toxbase. 2007. http://www.spib.axl.co.uk.
24. Mackway-Jones KM, Carley SD, Morton RJ, et al. The best evidence topic report: a modified CAT for summarising the available evidence in emergency medicine. Emerg Med J 1998;15:222-6. (Pubitemid 28356724)
25. Dunning J, Treasure T, Versteegh M, et al; on behalf of the EACTS Audit and Guidelines Committee. Guideline on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery. Eur J Cardiothorac Surg 2006;30:852-72. (Pubitemid 44738601)
26. Mackway-Jones KM, Carley SD, Morton RJ, et al. The best evidence topic report: a modified CAT for summarising the available evidence in emergency medicine. Emerg Med J 1998;15:222-6. (Pubitemid 28356724)
27. Oxford Centre for Evidence Based Medicine. 2007. http://www.cebm.net/?0= 1025.
28. Hulten BA, Adams R, Askenasi R, et al. Predicting severity of tricyclic antidepressant overdose. J Toxicol Clin Toxicol 1992;30:161-70.
29. Emerman CL, Connors AF, Burma GM. Level of consciousness as a predictor of complications following tricyclic overdose. Ann Emerg Med 1987;16:326-30. (Pubitemid 17025753)
30. Liisanantti J, Kaukoranta P, Martikainen M, et al. Aspiration pneumonia following self-poisoning. Resuscitation 2003;56:49-53.
31. Toxbase. 2007. http://www.spib.axl.co.uk.
32. Park C, Richell-Herren K. Activated charcoal in tricyclic antidepressant overdose. J Accid Emerg Med 2000;17:126-9.
33. Hedges JR, Otten EJ, Schroeder TJ, et al. Correlation of initial amitriptyline concentration reduction with activated charcoal therapy in overdose patients. Am J Emerg Med 1987;5:48-51. (Pubitemid 17018271)
34. Bosse GM, Barefoot JA, Pfiefer MP, et al. Comparison of three methods of gut decontamination in tricyclic antidepressant overdose. J Emerg Med 1995;13:203-9.
35. Hulten BA, Adams R, Askenasi R. Activated charcoal in tricyclic antidepressant poisoning. Hum Toxicol 1988;7:307-10.
36. Elliott CG, Colby TV, Kelly TM, et al. Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989;96:672-4.
37. Rajamani S, Allen P. Accidental charcoal aspiration. J Bronchol 2004;11:130-1. (Pubitemid 38580047)
38. Dorrington CL, Johnson DW, Brant R. The Multiple Dose Activated Charcoal Study Group. The frequency of complications associated with the use of multiple-dose activated charcoal. Ann Emerg Med 2003;41:370-7.
39. Givens T, Holloway M, Wason S. Pulmonary aspiration of activated charcoal: a complication of its misuse in overdose management. Pediatr Emerg Care 1992;8:137-40.
40. Harris CR. Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1992;22:1470-3. (Pubitemid 23253910)
41. Isbister GK, Downes F, Sibbritt D, et al. Aspiration pneumonitis in an overdose population: frequency, predictors and outcomes. Crit Care Med 2004;32:88-93. (Pubitemid 38125567)
42. Kulig W, Bar-Or D, Cantrill SV. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985;14:562-7. (Pubitemid 15040403)
43. Vale JA. Position statement: gastric lavage. J Toxicol Clin Toxicol 1997;35:711-19. (Pubitemid 28077832)
44. Watson WA, Leighton J, Guy J, et al. Recovery of cyclic antidepressants with gastric lavage [see comment]. J Emerg Med 1989;7:373-7. (Pubitemid 19215088)
45. Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med 1985;313:474-9. (Pubitemid 15015075)
46. Wrenn K, Smith BA, Slovis CM. Profound alkalemia during treatment of tricyclic antidepressant overdose: a potential hazard of combined hyperventilation and intravenous bicarbonate. Am J Emerg Med 1992;10:553-5.
47. McCabe JL, Cobaugh DJ, Menegazzi J, et al. Experimental tricyclic antidepressant toxicity: a randomized, controlled comparison of hypertonic saline solution, sodium bicarbonate and hyperventilation. Ann Emerg Med 1998;32:329-33. (Pubitemid 28413482)
48. Blackman K, Brown SGA, Wilkes GJ. Plasma alkalinization for tricyclic antidepressant toxicity: a systematic review. Emerg Med 2001;13:204-10. (Pubitemid 33051561)
49. Lomholt BS. [Hyperventilation therapy in acute tricyclic antidepressant poisoning. Controlled clinical research] [In Danish]. Ugeskr Laeger 1975;138:4-9.
50. Hoffman JR, Votey SR, Bayer M, et al. Effect of hypertonic sodium bicarbonate in the treatment of moderate-to-severe cyclic antidepressant overdose. Am J Emerg Med 1993;11:336-41. (Pubitemid 23227907)
51. Molloy DW, Penner SB, Rabson J, et al. Use of sodium bicarbonate to treat tricyclic antidepressant induced arrhythmias in a patient with alkalosis. Can Med Assoc J 1984;130:1457-9. (Pubitemid 14121254)
52. Seger DL, Hantsch C, Zavoral T, et al. Variability of recommendations for serum alkalinization in tricyclic antidepressant overdose: a survey of US poison center medical directors. J Toxicol Clin Toxicol 2003;41:331-8. (Pubitemid 36835526)
53. Knudsen K, Abrahamsson J. Magnesium sulphate in the treatment of ventricular fibrillation in amitriptyline poisoning. Eur Heart J 1997;18:881-2. (Pubitemid 27208164)
54. Weinberg G, Vade Boncouer T, Ramaraju GA, et al. Pretreatment or resuscitation with a lipid emulsion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology 1998;88:1071-5. (Pubitemid 28193335)
55. Weinberg G, Ripper R, Feinstein DL, et al. Lipid emulsion infusion rescues dogs from bupivacaine induced cardiac toxicity. Reg Anesth Pain Med 2003;28:198-202. (Pubitemid 36618312)
56. Van der Velde M, Woutens PF, Rolf N, et al. Long-chain triglycerides improve recovery from myocardial stunning in conscious dogs. Cardiovasc Res 1996;32:1008-15. (Pubitemid 26423389)
57. Harvey M, Cave G, Hoggett K. Correlation of plasma and peritoneal diasylate clomipramine concentration with haemodynamic recovery after intralipid infusion in rabbits. Acad Emerg Med 2009;16:151-6.
58. Harvey M, Cave G. Intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity. Ann Emerg Med 2007;49:178-85.
59. Brooks C. Intralipid use in TCA overdose. 2009. http://www.intralipid.org (accessed 18 Jan 2010).
60. Hagerman GA, Hanashiro PK. Reversal of tricyclic-antidepressant-induced cardiac conduction abnormalities by phenytoin. Ann Emerg Med 1981;10:82-6. (Pubitemid 12072753)
61. Cantrill S. Prophylactic phenytoin in tricyclic overdose. J Emerg Med 1983;1:169-77. (Pubitemid 14103890)
62. Perucca E, Richens A. Interaction between phenytoin and imipramine. Br J Clin Pharmacol 1977;4:485-6. (Pubitemid 8162365)
63. Shin J-G, Park J-Y, Kim M-J, et al. Inhibitory effects of tricyclic antidepressants (TCAs) on human cytochrome P450 enzymes in vitro: mechanism of drug interaction between TCAs and phenytoin. Drug Metab Dispos 2002;30:1102-7.
64. Callaham M, Schumaker H, Pentel P. Phenytoin prophylaxis of cardiotoxicity in experimental amitriptyline poisoning. J Pharmacol Exp Ther 1988;245:216-20.
65. Toxbase. http://www.spib.axl.co.uk. 2007.
66. Toxbase. http://www.spib.axl.co.uk. 2007.
67. Barnes RJ, Kong SM, Wu RWY. Electrocardiographic changes in amitriptyline poisoning. BMJ 1968;3:222-3.
68. Freeman JW, Mundy GR, Beattie RR, et al. Cardiac abnormalities in poisoning with tricyclic antidepressant. BMJ 1969;2:610-11.
69. Masters AB. Delayed death in imipramine poisoning. BMJ 1967;3:866-7.
70. McAlpine SB, Calabro JJ, Robinson MD, et al. Late death in tricyclic antidepressant overdose revisited. Ann Emerg Med 1986;15:1349-52. (Pubitemid 17184497)
71. Chan B, Gaudry P, Grattan-Smith TM, et al. The use of Glasgow Coma Scale in poisoning. J Emerg Med 1993;11:579-82. (Pubitemid 23318476)
72. Unverir R, Atilla R, Karcioglu O, et al. A retrospective analysis of antidepressant poisonings in the emergency department: 11-year experience. Hum Exp Toxicol 2006;25:605-12. (Pubitemid 44804783)
73. Yanagawa Y, Sakamoto T, Okada Y. Recovery from a psychotropic drug overdose tends to depend on the time from ingestion to arrival, the Glasgow Coma Scale, and a sign of circulatory insufficiency on arrival. Am J Emerg Med 2007;25:757-61. (Pubitemid 47385034)
74. Dawling S, Crome P, Braithwaite R. Effect of delayed administration of activated charcoal on nortriptyline absorption. Eur J Clin Pharmacol 1978;14:445-7. (Pubitemid 9076858)
75. Scheinin M, Virtanen R, Iisalo E. Effects of single and repeated doses of activated charcoal on the pharmaokinetics of doxepin. Int J Clin Pharmacol Ther Toxicol 1985;24:326-32.
76. Crome P, Dawling S, Braithwaite RA. Effect of activated charcoal on the absorption of nortriptyline. Lancet 1977;8050:1203-5. (Pubitemid 8237199)
77. Crome P, Adams R, Ali C. Activated charcoal in tricyclic antidepressant poisoning: pilot controlled clinical trial. Hum Toxicol 1983;2:205-9. (Pubitemid 13040468)
78. Karkkainen S, Neuvonen PJ. Pharmacokinetics of amitriptyline influenced by oral charcoal and urinary pH. Int J Clin Pharmacol 1986;24:326-32. (Pubitemid 16084164)
79. Swartz CM, Sherman A. The treatment of tricyclic antidepressant overdose with repeated charcoal. J Clin Psychopharmacol 1984;4:336-40. (Pubitemid 15214338)
80. Ilett KF, Hackett LP, Dusci LJ, et al. Disposition of dothiepin after overdose: effects of repeated-dose activated charcoal. Ther Drug Monit 1991;13:485-9.
81. Bailey B, Buckley NA, Amre DK. A meta-analysis of prognostic indicators to predict seizures, arrhythmias or death after tricyclic antidepressant overdose. J Toxicol Clin Toxicol 2004;42:877-88. (Pubitemid 39426214)
82. Eizadi-Mood N, Moein N, Saghaei M. Evaluation of relationship between arterial and venous blood gas values in the patients with tricyclic antidepressant poisoning. Clin Toxicol (Phila) 2005;43:357-60. (Pubitemid 41428768)
83. Brown TC, Barker GA, Dunlop ME, et al. The use of sodium bicarbonate in the treatment of tricyclic antidepressant-induced arrhythmias. Anaesth Intensive Care 1973;1:203-10.
84. Brown TC. Sodium bicarbonate treatment for tricyclic antidepressant arrhythmias in children. Med J Aust 1976;2:380-2.
85. Koppel C, Wiegreffe A, Tenczer J. Clinical course, therapy, outcome and analytical data in amitriptyline and combined amitriptyline/chlordiazepoxide overdose. Hum Exp Toxicol 1992;11:458-65. (Pubitemid 23023508)
86. Teba L, Scheibel F, Dedhia H, et al. Beneficial effect of norepinephrine in the treatment of circulatory shock caused by tricyclic antidepressant overdose. Am J Emerg Med 1988;6:566-8.
87. Vernon DD, Banner W, Garrett J, et al. Efficacy of dopamine and norepinephrine for the treatment of haemodynamic compromise in amitriptyline intoxication. Crit Care Med 1991;19:544-9.
88. Knudsen K, Abrahamsson J. Effects of epinephrine, norepinephrine, magnesium sulfate, and milrinone on survival and the occurrence of arrhythmias in amitriptyline poisoning in the rat. Crit Care Med 1994;22:1851-5. (Pubitemid 24346042)
89. Knudsen K, Abrahamsson J. Epinephrine and sodium bicarbonate independently and additively increase survival in experimental amitriptyline poisoning. Crit Care Med 1997;25:669-74. (Pubitemid 27193982)
90. Knudsen K, Abrahamsson J. Effects of epinephrine and norepinephrine on hemodynamic parameters and arrhythmias during a continuous infusion of amitriptyline in rats. Clin Toxicol 1993;31:461-71. (Pubitemid 23265204)
91. Ruddy JM, Seymour JL, Anderson NG. Management of tricyclic antidepressant ingestion in children with special reference to the use of glucagon. Med J Aust 1972;1:630-3.
92. Sener EK, Gabe S, Henry JA. Response to glucagon in imipramine overdose. J Toxicol Clin Toxicol 1995;33:51-3.
93. Sensky PR, Olczak SA. High dose intravenous glucagon in severe tricyclic poisoning. Postgrad Med J 1999;75:611-12. (Pubitemid 29452592)
94. Citak A, Soysal DD, Ucsel R, et al. Efficacy of long duration resuscitaiton and magnesium sulphate treatment in amitriptyline poisoning. Eur J Emerg Med 2002;9:63-6.
95. Minton NA, Goode AG, Henry JA. The effect of a lipid suspension on amitriptyline disposition. Arch Toxicol 1987;60:467-9. (Pubitemid 17137309)
96. Greenland P, Howe TA. Cardiac monitoring in tricyclic antidepressant overdose. Heart Lung 1981;10:856-9. (Pubitemid 12182077)
97. Pentel P, Sioris L. Incidence of late arrhythmias following tricyclic antidepressant overdose. Clin Toxicol 1981;18:543-8. (Pubitemid 11017521)
98. Goldberg RJ, Capone RJ, Hunt JD. Cardiac complications following tricyclic antidepressant overdose. JAMA 1985;254:1772-5. (Pubitemid 15237963)
99. Emerman C, Connors AF, Burma GM. Level of consciousness as a predictor of the complications following tricyclic overdose. Ann Emerg Med 1987;16:326-30. (Pubitemid 17025753)
100. Tokarski GF, Young MJ. Criteria for admitting patients with tricyclic antidepressant overdose. J Emerg Med 1988;6:121-4.
101. Banahan B, Schelkun P. Antidepressant overdose: conservative management in the community hospital with cost saving implications. J Emerg Med 1990;8:451-4. (Pubitemid 20288767)
102. Hulten BA, Adams R, Askenasi R, et al. Predicting severity of tricyclic antidepressant overdose. J Toxicol Clin Toxicol 1992;30:161-70.