Tricyclic antidepressant poisoning treated by magnesium sulfate: a randomized, clinical trial

Abstract

Tricyclic antidepressant (TCA) poisoning is a major problem in medicine, with a high morbidity and mortality rate. The main cause of fatality is cardiac arrhythmias resulting from intoxication. Sodium bicarbonate is the drug of choice, but severe poisoning necessitates further interventions. Magnesium sulfate seems to be effective in this condition. In a randomized, clinical trial, we evaluated all patients with a history of TCA intoxication referred to the Loghman Hakim Hospital Poison Center. The patients were randomly divided into two groups: one treated by bicarbonate infusion (control group) and the other (case group) by the infusion of magnesium sulfate in addition to the treatment in the first group. Seventy-two patients were recruited into the study (36 cases and 36 controls). Mean duration of intensive care unit stay in the cases and controls were 25.63 ± 9.33 and 82.67 ± 21.66 hours, respectively (P < 0.001). Mortality rate in the case group was 13.9% and 33.3% in the other group (P = 0.052). Magnesium sulfate can be an effective drug in the treatment of TCA poisoning; however, several randomized, clinical trials are still necessary to confirm this.

Survival after severe amitriptyline poisoning with prolonged ventricular tachycardia and cardiac arrest

“…Although severe TCA poisoning is associated with metabolic acidosis, secondary to myocardial dysfunction with hypotension, resulting in tissue hypo-perfusion and lactic acidosis, our patient did not have acidosis at any stage [ 4 ]. There are few cases reported, on severe TCA poisoning where failing initial resuscitation, they have tried new strategies such as intra venous lipid emulsion [ 7 ], percutaneous cardiopulmonary support [ 8 ] and use of intravenous magnesium sulfate [ 9 ]. But the actual benefits of these methods are yet to be proven.…”

Antihistamines

“…H 1 receptors are thought to have a modulatory role in the CNS, affecting numerous functions, including sleep-wake cycles, thirst, thermoregulation, and prevention of seizures [12,13]. Antagonism of central H 1 receptors can result in somnolence [14] and seizures [15].…”

“…Traditionally, antihistamine-induced seizures were thought to be due to either their local anesthetic effects or their anticholinergic effects. Antihistamines' ability to cause seizures does not correlate, however, with their affinity for muscarinic receptors and is not reversed by physostigmine [15,17]. Laboratory studies in mice and rats using histidine, a histamine precursor, and blockers of histamine metabolism have shown significant decreases in the incidence of experimentally induced seizures, suggesting that histamine may play a role in the CNS in seizure prevention.…”

“…Sodium bicarbonate infusions of 100-150 mL in 1000 mL of 5 % dextrose in water (with potassium chloride added) often have been used after conversion of ventricular tachycardia, although the scientific basis for this practice is marginal (see chapter "▶ Sodium Channel Blocking Anti-dysrhythmics"). Lidocaine is a second-line drug for ventricular tachycardia (LOE III), and magnesium sulfate has also been used successfully (LOE I) [15,116,117]. The role of amiodarone is less clear, and concerns of the development of torsades de pointes have been raised [118] because of its tendency to prolong the QTc.…”

Prescription patterns of Chinese herbal products for patients with sleep disorder and major depressive disorder in Taiwan

“…Tricyclic antidepressants used to treat MDD can cause cardiac toxicity (Emamhadi et al, 2012) and selective serotonin reuptake inhibitors are associated with sexual dysfunction (Montejo et al, 2001).…”