Rapid diagnosis and treatment of severe tricyclic antidepressant toxicity

Abstract

A woman in her mid-50s contacted her social worker and expressed intent to commit suicide by ingesting prescription medications. On arrival of emergency responders, the patient was found unconscious with an empty bottle of amitriptyline. Time of ingestion was estimated using the social worker's contact with local authorities. The patient's presentation at the emergency department (ED) exemplified tricyclic antidepressant toxidrome with a poor prognosis, based on measurable criteria and physical findings. Respiratory and cardiovascular collapse was managed emergently. Haemodynamic status and EKG findings responded in a stepwise fashion with therapy in the ED and intensive care unit. Full clinical recovery took 7 days, and the patient was subsequently transferred to an in-patient psychiatric facility for further evaluation. Eight days later, she was discharged home with no neurological sequelae.

Electrocardiogram Abnormality in Poisoned Patients with Tricyclic Antidepressant

“…TCAs stand out as one of the leading causes of drug poisoning ( 2 ), despite the availability of safer alternatives with a less toxic profile, such as selective serotonin reuptake inhibitors (SSRIs). Surprisingly, TCAs continue to be prescribed extensively for various indications in both children and adults, ( 3 ) ranging from major depressive disorders to chronic pain syndromes, panic attacks, severe anxiety, phobic disorders, obsessive-compulsive disorders, migraine, eating disorders, and attention deficit hyperactivity disorders ( 4 ). Their mechanism involves primarily blocking norepinephrine and postsynaptic α-adrenergic receptors while also influencing the cholinergic and histaminergic systems and α-adrenergic activity, along with quinidine-like effects on cardiac condition ( 2 , 3 , 5 ).…”

“…Surprisingly, TCAs continue to be prescribed extensively for various indications in both children and adults, ( 3 ) ranging from major depressive disorders to chronic pain syndromes, panic attacks, severe anxiety, phobic disorders, obsessive-compulsive disorders, migraine, eating disorders, and attention deficit hyperactivity disorders ( 4 ). Their mechanism involves primarily blocking norepinephrine and postsynaptic α-adrenergic receptors while also influencing the cholinergic and histaminergic systems and α-adrenergic activity, along with quinidine-like effects on cardiac condition ( 2 , 3 , 5 ). Tricyclic antidepressants possess a narrow therapeutic index, primarily responsible for inducing adverse effects and accounting for a significant proportion of severe poisoning cases after TCAs overdose.…”