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Tricyclic antidepressant overdose

Definition
TCA overdose is defined as ingestion of TCA at above the recommended therapeutic dose.
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Pathophysiology
TCA overdose may be accidental or intentional, including as part of suicide attempts.
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Epidemiology
The incidence of TCA overdose is estimated at 3.8 per 100,000 person-years.
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Disease course
TCAs block alpha-adrenergic receptors and have anticholinergic effects, leading to tachycardia, hypotension, cardiac conduction abnormalities, and arrhythmias. TCAs also exert a number of effects on the CNS, which may lead to drowsiness, coma, respiratory depression, seizures, and delirium.
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Prognosis and risk of recurrence
Hospital admission and intensive care support are required in several patients. Fatality rates of up to 6% have been reported in patients with severe overdose.
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Key sources
The following summarized guidelines for the evaluation and management of tricyclic antidepressant overdose are prepared by our editorial team based on guidelines from the Guidelines in Emergency Medicine Network (GEMNet 2011).
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Guidelines

1.Diagnostic investigations

Electrocardiogram: obtain an ECG in all patients presenting to hospital following TCA overdose.
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  • Blood gas analysis

2.Respiratory support

Airway protection
Perform endotracheal intubation in patients with severely altered mental status (e.g. GCS ≤ 8) using rapid sequence induction.
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Consider performing endotracheal intubation in patients with other features suggestive of airway compromise, hypoventilation or refractory seizures.
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3.Medical management

Gastric decontamination: consider using activated charcoal in patients with TCA overdose who present within 1 hour of ingestion and have an intact or secured airway. The potential risk of aspiration should be strongly considered before use.
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  • Management of agitation

  • Management of seizures

  • Management of hypotension

  • Management of dysrhythmias

4.Follow-up and surveillance

Discharge from hospital: consider discharging asymptomatic patients with no signs of instability and no significant electrocardiographic changes at 6 hours after ingestion following TCA overdose.
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