TCA toxicology

2. Toxicology
Dr. M.M. Shater
TRICYCLIC ANTIDEPRESSANTS
ROSEN’S
EMERGENCY MEDICINE
Concepts and Clinical Practice

3. Principles of Toxicity
 In the 1950s, imipramine became the first TCA used for the treatment of
depression.
 use for other conditions, including treatment of migraines, various neuropathies,
trigeminal neuralgia, and nocturnal enuresis has increased.

4. Clinical Features
 Cyclic antidepressant toxicity can result from overdose of a TCA or drug
interactions.
 Cytochrome P450
 Desipramine and nortriptyline
 serotonin syndrome(MAOI or SSRI)

5. Clinical Features
 After an overdose of a TCA, symptoms typically begin within 1 to 2 hours.
 within the first 2 hours:
 anticholinergic effects(dry mucosal membranes, urinary retention, and hot, dry
skin)
 Pupils are often small
 Patients may be alert and confused, severely agitated, mute, hallucinating, or
even deeply comatose
 Speech is often rapid and mumbling in character
 Seizures
 Early hypertension , hypotension may also be due

6. Clinical Features
 Later (2 to 6 hours post ingestion):
 myocardial depression
 hypotension and bradycardia
 widening of the QRS interval(prognostic):100 , 160 msec
 prolonged QT interval
 Severe: depressed level of consciousness, seizures, hypotension, and wide-
complex cardiac arrhythmias.

7. Clinical Features
 Chronic toxicity:
 Confusion, urinary retention, and prolonged corrected QT (QTc) interval are
common.

8. Differential Diagnoses
 Diphenhydramine and carbamazepine
 Cocaine
 serotonin syndrome
 procainamide, disopyramide, quinidine
 flecainide, encainide, and propafenone
 Propoxyphene and propranolol
 amantadine, mesoridazine, and thioridazine.

9. Key
 The constellation of early anticholinergic symptoms, decreased level of
consciousness followed by seizures, wide QRS, and cardiovascular collapse is
highly suggestive of acute TCA overdose.

10. Diagnostic Testing
 ECG:
 sinus tachycardia
 (aVR) demonstrating tall R wave
 QT prolongation
 Urine drug of abuse screens commonly test for the presence of TCAs, but a
positive test result suggests only use of a TCA or another xenobiotic that cross-
reacts with the screen.
 Urine drug of abuse screens commonly test for the presence of TCAs, but a
positive test result suggests only use of a TCA or another xenobiotic that cross-
reacts with the screen

11. Management
 Ensuring stability of the airway, with adequate ventilation, and volume repletion
are of primary importance.
 activated charcoal
 Patients with sinus tachycardia alone do not need specific treatment but should
be monitored to detect QRS widening early in the clinical course.
 Early hypertension should not be treated
 Hypotensive patients should first receive fluid resuscitation with an isotonic
crystalloid. Patients who remain hypotensive should be treated with direct-acting
vasopressors such as norepinephrine and epinephrine.

12. Management
 Hypertonic sodium bicarbonate
 Class Ia or Ic antidysrhythmics should be avoided.
 Seizures are best treated with an IV benzodiazepine
 Refractory seizures can be treated with phenobarbital
 Acidosis and intubation
 Physostigmine
 Intravenous lipid emulsion (ILE)

13. Disposition
 If the heart rate has not exceeded 100/minute for a period of at least 10 minutes,
ECG intervals are normal, level of consciousness is normal, and no seizures have
developed within 6 hours of a TCA overdose, it is unlikely that toxicity will occur.
The patient can be medically cleared from the emergency department for
psychiatric evaluation and disposition if needed.
 Patients with signs of cyclic antidepressant cardiotoxicity, seizures, or coma
should be admitted to an intensive care unit.