[Deaths caused by antidepressive agents and neuroleptics. Risk groups illustrated by a forensic material]

At the Institute of Forensic Medicine, University of Oslo, legal autopsy was performed on 153 persons who died from poisoning by neuroleptics and/or antidepressants from 1986 to 1989. In one third of the cases, only neuroleptics were found at autopsy, and in little less than half of these cases the post mortem blood concentrations were considered rather low in relation to the fatal outcome. A larger proportion of alcohol abusers were found in the group with low post mortem concentrations of neuroleptics than in the rest of the material. This group contained mainly men and was further characterized by a high proportion of unintentional deaths. In the light of these facts the authors speculate whether neuroleptics represent increased risk of sudden death among alcohol abusers. The deaths due to an overdose of antidepressants were mostly suicides, and involved high post mortem blood concentrations of the drugs.

HPLC quantification of zolpidem and prothipendyl in a voluntary intoxication

Zolpidem, a recently developed sleep inducer, and prothipendyl, a neuroleptic azaphenothiazine, were involved in a voluntary intoxication along with ethanol. After administration of flumazenil, a specific benzodiazepines antagonist, respiratory depression was corrected. HPLC with UV detection methods after selective extraction were developed to measure simultaneously prothipendyl and zolpidem without flumazenil interaction. These methods could be applied in drug monitoring and in emergency toxicology.

Adverse cardiac effects of combined neuroleptic ingestion and tricyclic antidepressant overdose

During a retrospective review of 70 consecutive intensive care unit admissions for tricyclic antidepressant (TCA) overdose, we identified 12 patients (17%) who had simultaneously ingested a neuroleptic agent. We then compared several clinical and laboratory features of patients who had ingested TCAs alone with those patients who had also taken a neuroleptic drug. The 12 patients in the TCA-neuroleptic group, when compared with patients in the TCA-only group, showed a markedly higher prevalence of first-degree atrioventricular block (p less than 0.001), a significantly higher prevalence of prolongation of the QRS duration (greater than 0.10 sec) (p less than 0.05), and a threefold increase in the prevalence of QTc prolongation (p less than 0.05). Our data indicate that coingestion of neuroleptics and TCAs, when compared with the ingestion of TCA alone, may significantly increase the risk of adverse cardiac consequences. We discuss the possible mechanisms for these electrocardiographic changes as well as their potential implications.

Tricyclic neuroleptic and antidepressant overdose: epidemiological, electrocardiographic, and clinical features--a survey of 92 cases

From 1976 to 1980, there were 3,193 admissions due to acute drug overdosage at the resuscitation centre of the Rudolf-Virchow-Hospital, Free University of Berlin. The frequency and the characteristics of selfpoisoning with antidepressants and low-potency neuroleptic drugs (mainly perazine and thioridazine) were determined. These drugs were involved in 92 cases (3%) during this five-year period. Amitriptyline--in combination with a benzodiazepine--was the most common antidepressant taken by the patients. Ten of the patients required assisted ventilation. Complete ECG recordings were carried out in 24 patients. The most common abnormality was a prolonged QTc interval (21 patients) followed by a QRS duration of 0.11 seconds or longer (17 patients). Sinus tachycardia was present in half of the cases. In no cases did the medical records describe convulsions or cardiac arrhythmias requiring special treatment. The percentage of patients showing ECG changes and respiratory depression was higher when other drugs such as ethanol were ingested along with antidepressants than when only antidepressants were taken. One patient died after six weeks in hospital due to a complicated abscess. From 1976 to 1980, the incidence of antidepressant selfpoisoning was relatively low compared with findings from other studies. Data from other studies suggest that, in the period 1980-1987, there was an increase in the incidence of antidepressant selfpoisoning, at least in the West Berlin and Munich areas. However, these figures are much lower than those reported by British, American, and Australian authors.

Clinical experiences with Ro 15-1788 (anexate) in benzodiazepine and mixed-drug overdoses

Benzodiazepine overdose is the most common of admission to the Toxicological Unit of the University of Florence. The aim of this study has been to evaluate the efficiency of Ro 15-1788 in benzodiazepine and mixed drug overdoses. The administration of Ro 15-1788 was followed by a quick reversal of central nervous system depression and was more effective in benzodiazepine overdoses than in mixed drug overdoses. The dose was titrated individually and the range 2-10 mg was effective according to the conditions of the patient. In some cases, the comatose state relapsed; further administration of Ro 15-1788 again promptly reversed the condition. On awakening, two patients displayed anxiety and restlessness.

[Failure of gastric lavage in severe drug poisoning. Value of esophagogastric fibroscopy]

A case is reported of massive drug self-poisoning (more than 200 pills associated with slices of oranges) in which repeated gastric lavage failed to empty the stomach. An attempt to split up the amalgamated pills, adherent to the gastric mucosa, by fibre-optic gastroscopy failed and a gastrotomy was required. Endoscopy together with gastric lavage is indicated in certain situations to quickly empty the stomach and so shorten the course of the poisoning. Indications are the large number of pills swallowed, a poor result of the treatment, a worsening of the clinical condition despite treatment, and three positive gastric toxicological assays within the first 24 h.

Trends in self-poisoning with drugs in Newcastle, New South Wales, 1980-1982

A review has been carried out of 747 cases of self-poisoning with drugs which were treated in the three major Newcastle hospitals over the three-year period 1980-1982. The data obtained have been compared with earlier published data for the years 1976-1979. The number of patients who were admitted to hospital fell from 290 in 1980 to 226 in 1982. The most common drugs used were benzodiazepine (34.5% of cases) and antidepressant agents (9.1%), paracetamol (7.9%), barbiturates (7.1%) and phenothiazines (3.8%). Although this indicated a gratifying drop in the use of barbiturate drugs, the use of several drugs in combination in self-poisoning rose disturbingly. Five patients died in hospital; 23 who committed suicide with drugs were not admitted to hospital but were investigated by the Regional Forensic Pathologist.

Self-poisoning treated in an ICU: drug pattern, acute mortality and short-term survival

A total of 1558 admissions to an ICU over 5 years because of severe self-poisoning with drugs provides the basis for this study. Three drugs accounted for 60% of the admissions: overdose with barbiturates in 28%, with tricyclic antidepressants in 19% and with propoxyphene in 14%. The annual incidence of poisonings with barbiturates and tricyclic antidepressants was the same during the period, whereas the incidence of propoxyphene intoxication increased by 80%. Intensive supportive care was the main principle of treatment. All patients were artificially ventilated. The mortality rate was 6.1%, salicylate, propoxyphene and strong analgesics having the highest mortalities (11%, 9% and 9%, respectively). A mortality rate of 3% was found following overdose with tricyclic antidepressants. By 36 months after the overdose, 235 patients (18%) had died. The expected number of deaths was 39 (3%). The suicide rate in the follow-up period was 10%, in the majority (75%) of whom death was caused by a new episode of self-poisoning.

Management of overdose with psychoactive medications

General management of the patient who has ingested an overdose of psychoactive medication is emphasized, since the suicidal patient has almost invariably taken multiple substances and often alcohol as well. The drug groups considered in detail include the sedative hypnotics, tricyclic antidepressants, phenothiazines, and lithium.

[EEG in the prognosis of toxic coma: reflections apropos of unusual data]

During acute intoxications, the first EEG may show persistence or abolition of cerebral activity, but the possibility of recovery after isoelectric tracing in toxic comas must be emphasized. EEG patterns frequently suggest the probability of hypnotic tranquilizer poisoning; 4 types of EEG are encountered corresponding to different grades of toxic coma. Recurrent periods of electrical silence alternating with bursts of activity are habitually recorded in carus comas with hypothermia due to acute barbiturate intoxication, with good prognosis. The possibility of a neurological disturbance associated with drug overdose must be raised whenever an asymmetric tracing is encountered. Serial recordings may detect complications such as: a localized lesion, anoxia or, very rarely, typical paroxysmal abnormalities reappearing in comitial patients before emergence from a toxic coma. Paradoxical monomorphic delta activity corresponding to improvement must not be considered as an aggravation. Peculiar EEG findings occur after oral trichlorethylene poisoning, with temporary clinical deterioration and intermittent periods of electrical silence; recovery is possible. An alpha-like pattern after cardiac arrest of toxic origin has a poor prognosis. The appearance of alternating patterns suggests the development of irreversible brain damage.