While the incidence of TCA overdose is far lower than other medications, a 2004 to 2017 review of drug overdoses showed that the case fatality rate in TCA overdose was 3.98%. When you walk in the room, a tech hands you this ECG:After glancing at the ECG, you look at your patient. Podcast 98 – Cyclic (Tricyclic) Antidepressant Overdose.
Frequently, patients who have overdosed on TCA’s are obtunded and require rapid intubation and ventilation. In small children one or two pills can be fatal. “Impending cardiovascular toxicity in adult patients [with TCA poisoning] is usually preceded by specific ECG abnormalities: the majority of pateints at significant risk will have a QRS duration >100ms or a rightward shift (130-270) of the terminal 40ms of the frontal plane QRS vector. [Updated 2019 Apr 6]. Amal Mattu’s ECG Case of the Week – February 11, 2019. HR: 128 bpm, PR interval: N/A, QRS: 146 ms, Qt/QTc: 430/627 ms, P-R-T axes: */-61/94Figure 2: EKG of patient after sodium bicarb.
Morbidity and Mortality Associated with Medications Used in the Treatment of Depression, An Analysis of Cases Reported to U.S. For comparison, the opiate overdose fatality rate was 2.79%. Tricyclic antidepressant poisoning. For comparison, the opiate overdose fatality rate was 2.79%. TCAs were associated with the second-highest morbidity for all drugs used to treat depression during this period of time.Due to the multisystem involvement of TCA toxicity, a broad differential diagnosis should be considered.CNS depression should lead to the consideration of sedatives, alcohols, opiates/opioids, carbon monoxide, and antipsychotics.Seizures can be seen in many conditions including epilepsy, alcohol withdrawal, cocaine use, and salicylate poisoning.Anticholinergic side effects can be seen with a litany of both prescribed and over the counter medications.Hypotension in the setting of tachycardia can occur with many antihypertensive medications like alpha antagonists, calcium channel blockers, and nitrates.QRS widening can be due to cocaine, sodium channel antagonists, phenytoin, and diphenhydramine.While TCA overdoses are not the most common, seizure or CNS depression in the setting of widened QRS or hypotension should place TCA toxicity at the top of your differential.TCAs have a narrow therapeutic index, 10-20 mg/kg can be life threatening and signs of toxicity are clinically apparent between 30 minutes to 2 hoursTCA toxicity primarily manifests from cardiac and CNS symptomsGiwa A, Oey E. The return of an old nemesis: Survival after severe tricyclic antidepressant toxicity, a case report.
The patient started with a confused mental state and decreased to a GCS of eight, potentially indicating the need for an advanced airway. The Emergency Medical Minute (EMM) is a Colorado 501(c)(3) non-profit organization promoting free medical education to nurses, medics, doctors & other clinicians.
Post was not sent - check your email addresses!
The EKG findings in TCA overdose vs. controls are highlighted in the table. Design: Prospective cohort series of referral cells from hospitals to a regional poison control center. The shift away from using TCAs for depression was in large part due to the drug’s narrow therapeutic index, which predisposes patients to overdose. The patient was later admitted to the ICU where she made a full recovery.We are actively recruiting both new topics and authors.
Enter your email address to receive notifications of new posts by email.This blog aims to disrupt how medical providers and trainees can gain public access to high-quality, educational content while also engaging in a dialogue about best-practices in EM and medical education. In the ED it is a clinical diagnosis.An EKG and serum blood glucose level should be obtained immediately upon presentation.
Sorry, your blog cannot share posts by email. Group Management; Group Progress Report; Group Cases; FAQ; Our Team; Join Today! ECG Weekly; CME; ECGStat; Pricing; Weekly Cases; Group Purchase. neuropathic pain or fibromyalgia).Cardiac toxicity can develop quickly in TCA overdose, so obtaining an ECG early in the clinical course is key. Fun fact: The mechanism of action that sodium bicarb works to fix a TCA overdose is not completely known.
Patients may present with hypotension from alpha-blockade, symptoms of anticholinergic toxicity, QRS prolongation, QT prolongation, hypokalemia, and seizures. International Journal of Drug Policy. 2020;76. Amal Mattu’s ECG Case of the Week – February 24, 2020. This is one of the first papers stating that an EKG has diagnostic sensitivity in unknown or suspected TCA overdose. As always, the first step in evaluating the patient is assuring their airway, breathing, and circulation are stable. If pH is >7.5 and the QRS is still wide, a switch to a lidocaine drip should be used.QT/QTc prolongation also needs immediate addressing to prevent fatal ventricular arrhythmias and Torsades de Pointes.