Citalopram overdose: Late presentation of torsades de pointes (TdP) with cardiac arrest

Tarabar, Asim F.; Hoffman, Robert S.; Nelson, Lewis S.

doi:10.1007/bf03160963

Cited by 64 publications

(47 citation statements)

References 14 publications

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“…The mechanism of cardiac toxicity is thought to be, in part, mediated by one of its metabolites, didemethylcitalopram (DDCT), and its blockade of the inward rectifier potassium channel [12]. As a consequence of QT prolongation, torsades des pointes has also been described in citalopram overdose [5] and was seen in our patient.…”

Section: Discussionsupporting

confidence: 50%

“…Yet even with high-dose ingestions, most patients fully recover. There have been very few reports of fatal citalopram overdoses without coingestants [5,8]. We report a case of an isolated, citalopram overdose resulting in death.…”

Section: Introductionmentioning

confidence: 91%

“…In general, selective serotonin reuptake inhibitors (SSRIs) have been shown to be safer in overdose than tricyclic antidepressants (TCAs) and the rate of suicide from antidepressant intoxication decreased after their introduction [2]. However, citalopram is considered to have the most potential for cardiac and neurologic toxicity among the SSRIs and there are numerous case reports of these toxicities in overdose [3][4][5]. Serotonin syndrome may also occur following overdose [6,7].…”

Section: Introductionmentioning

confidence: 99%

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Citalopram Overdose: a Fatal Case

Kraai

Seifert

2014

J. Med. Toxicol.

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Background Citalopram is a selective serotonin reuptake inhibitor (SSRI) with cardiac and neurologic toxicities as well as the potential for serotonin syndrome. In most instances, patients recover fully from toxic ingestions of SSRIs. We describe a fatal case of a citalopram overdose. Case Report A 35-year-old woman presented to the emergency department after having witnessed seizures at home. An empty citalopram prescription bottle was located, and an intentional overdose was suspected. At the scene, she was found to be in cardiac arrest with pulseless electrical activity and underwent cardiopulmonary resuscitation, including intravenous epinephrine and bicarbonate. In the emergency department, her physical exam was notable for cough and gag reflexes and movement in all extremities with increased muscle tone and tachycardia. Her initial postresuscitation ECG showed sinus rhythm with QRS 92 ms and QTc 502 ms. Her temperature was initially normal, but she rapidly became febrile to 41.8°C shortly after admission. She was treated symptomatically and with cyproheptadine for suspected serotonin syndrome (SS) but became increasingly hemodynamically unstable over the next 6 h and then developed torsades des pointes (TdP) progressing to pulseless, wide complex tachycardia. She underwent cardiopulmonary resuscitation (CPR) for approximately 50 min but ultimately expired. Postmortem serum analysis revealed a citalopram concentration of 7300 ng/mL (therapeutic range 9-200 ng/mL) and THC, but no other nonresuscitation drugs or substances. Case Discussion Citalopram overdoses often have only mild to moderate symptoms, particularly with ingestions under 600 mg in adults. However, with higher doses, severe manifestations have been described, including QTc prolongation, TdP, and seizures. Serotonin syndrome has also been described in SSRI overdose, and our patient exhibited signs consistent with SS, including increased muscle tone and autonomic dysregulation. Our patient's serum concentration suggests a massive overdose, with major clinical effects, possible SS, and death. Conclusions Although most patients recover from citalopram overdose, high-dose ingestions can produce severe effects and fatalities may occur. In this case, it is likely that the patient's delayed presentation also contributed significantly to her death. The clinician must be aware of the potential for large ingestions of citalopram to produce life-threatening effects and monitor closely for the neurologic, cardiovascular, and other manifestations that, in rare cases, can be fatal.

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Section: Discussionsupporting

confidence: 50%

Section: Introductionmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 99%

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Citalopram Overdose: a Fatal Case

Kraai

Seifert

2014

J. Med. Toxicol.

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“…There were several level 4 or 6 articles with individual case information presented in detail. Specifically, there were 12 cases reported in 11 articles (42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52). Among them, the lowest dose of citalopram associated with any toxicity was 400 mg, which was reported to be associated with severe toxicity in at least two adults (42,47).…”

Section: Citaloprammentioning

confidence: 99%

“…There was a level 3b combined retrospective and prospective report of 52 sertraline ingestions in which the onset of effects was reported as occurring within ½-10 hours of ingestion (37). There were published cases in which significant toxic effects (e.g., serotonin syndrome, cardiac toxicity, or seizures) occurred 4-24 or more hours after ingestion, but in all such cases at least some signs or symptoms (albeit mild in some cases) were present earlier in the patient's course (37,39,47,51,56,57,61,90,97). In a retrospective review of 44 cases of citalopram ingestion, seizures were noted to occur "within the first few hours" while ECG effects like QRS or QTc changes, were noted "later" (43).…”

Section: Onset Of Effectsmentioning

confidence: 99%

Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management

Nelson

Erdman

Booze

et al. 2007

Clinical Toxicology

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American Association of Poison Control Centers, Washington, District of Columbia, USAA review of US poison center data for 2004 showed over 48,000 exposures to selective serotonin reuptake inhibitors (SSRIs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidencebased expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments.The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with a suspected ingestion of an SSRI by 1) describing the process by which an ingestion of an SSRI might be managed, 2) identifying the key decision elements in managing cases of SSRI ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of immediate-release forms of SSRIs alone. Co-ingestion of additional substances might require different referral and management recommendations depending on their combined toxicities.This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment.Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department. This activity should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) Any patient already experiencing any symptoms other than mild effects (mild effects include vomiting, somnolence [lightly sedated and arousable with speaking voice or light touch], mydriasis, or diaphoresis) should be transported to an emergency department. Transportation via ambulance should be considered based on the condition of the patient and the length of time it will take the patient to arrive at the emergency department (Grade D). 3) Asymptomatic patients or those with mild effects (defined above) following isolated unintentional acute SSRI ingestions of up to five times an initial adult therapeutic dose (i.e., citalopram 100 mg, escitalopram 50 mg, fluox...

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Psychotropic Drugs in Special Conditions

2021

The Maudsley Prescribing Guidelines in Psychiatry

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This chapter provides brief details of the toxicity in overdose of commonly used psychotropics. It is intended to help guide drug choice in those thought to be at risk of suicide, to give some indication of safe quantities to prescribe and to help identify symptoms of overdose. In all cases of suspected overdose, urgent referral to acute medical facilities is, of course, strongly advised. Everyone has a duty to drive reasonably, and in almost all countries drivers are legally responsible for accidents they cause whether or not under the influence of drugs and alcohol. Many factors have been shown to affect driving performance. In the UK, severe mental disorder is a prescribed disability for the purposes of the Road Traffic Act 1988. Many psychotropics can impair alertness, concentration and driving performance. There are few studies of the effects of non‐anaesthetic drugs on surgery and the anaesthetic process.

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Citalopram overdose: Late presentation of torsades de pointes (TdP) with cardiac arrest

Abstract: Citalopram overdose can produce life-threatening cardiac toxicity with a clinical onset that may be delayed beyond a routine observation period of 6 hours. Once the QT interval is prolonged, it seems prudent to prolong the observation period.

Cited by 64 publications

References 14 publications

Citalopram Overdose: a Fatal Case

Citalopram Overdose: a Fatal Case

Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management

Psychotropic Drugs in Special Conditions

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