TCA toxicity - NYSORA

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TCA toxicity

TCA toxicity

Learning objectives

  • Diagnose and treat TCA toxicity

Definition and mechanisms

  • Tricyclic antidepressants (TCAs) are used to treat depression, chronic pain, and some forms of acute pain
  • The mode of action is by the prevention of presynaptic re-uptake of norepinephrine and serotonin
    • Also anti-muscarinic, antihistaminergic, and anti-a1-adrenergic effects
  • TCA toxicity is caused by excessive medication of:
    • Amitriptyline
    • Imipramine
    • Nortriptyline
    • Doxepin
    • Dothiepin
    • Clomipramine   
  • TCAs have a narrow therapeutic index which carries a high risk of toxicity
  • Most poisoning presentations are from acute ingestion; however chronic poisoning can also present acutely
  • A dose >10mg/kg can be potentially life-threatening
  • Severe toxicity usually manifests itself within 2 and no later than 6 hours after ingestion
  • Exclude co-ingestion of other toxic agents (eg. paracetamol) 
  • Excess sodium bicarbonate can be lethal due to severe hypernatremia, hypokalemia, and alkalemia, don’t give more than 6 mmol/kg 
  • The goals of sodium bicarbonate treatment are:
    • pH 7.5-7.55
    • Max. Na 155 mmol/L
    • QRS <140 ms

Signs and symptoms

Anticholinergic effectsFever
Inability to sweat
Dry mouth
Mydriasis
Blurred vision
Constipation
Urinary retention
Cardiovascular effectsSinus tachycardia
Hypotension
ABG: mixed acidosis with both respiratory depression and ↑ lactate
ECG:
QRS and PR/QT prolongation
Large terminal R wave in aVR,
Predisposing to broad complex tachyarrhythmia (VT)
Central nervous systemChange in mental status
Agitation
Seizures
Coma

Treatment

TCA toxicity, ECG, sodium bicarbonate, benzodiazepines, crystalloids, activated charcoal, VA-ECMO, vasopressords cardioversion

Anesthetic management

TCA toxicity, co-ingestants, ephedrine, metaraminol, directly acting sympathomimetics, cholinergic symptoms

Suggested reading

  • Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances [published correction appears in Resuscitation. 2021 Oct;167:91-92]. Resuscitation. 2021;161:152-219.
  • Peck, T., Wong, A., Norman, E., 2010. Anaesthetic implications of psychoactive drugs. Continuing Education in Anaesthesia Critical Care & Pain 10, 177–181.
  • Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J. 2001;18(4):236-241. doi:10.1136/emj.18.4.236

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