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Simon M, Kaplan S, Muschler K, Hoyte C, Brent J. The role of QRS complex prolongation in predicting severe toxicity in single-xenobiotic overdose. Clin Toxicol (Phila) 2024; 62:32-38. [PMID: 38329803 DOI: 10.1080/15563650.2024.2307356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The QRS complex duration is commonly used to prognosticate severity, predict outcomes, and indicate treatment in overdose. However, literature to support this practice is mixed in tricyclic antidepressant overdoses and absent in non-tricyclic antidepressant overdoses. Our objective was to assess the validity of QRS complex duration as a prognostic marker in overdose. METHODS This was a secondary analysis of cases reported to the Toxicology Investigators Consortium between January 1, 2010, and December 31, 2022. Cases were assessed to determine the six xenobiotics most associated with QRS complex prolongation. All cases involving these six xenobiotics, regardless of QRS complex duration, constituted the study cohort. Inclusion criteria were cases of patients older than 12 years old with single-xenobiotic exposures. Clinical outcomes evaluated were seizure, ventricular dysrhythmia, metabolic acidosis, and death. RESULTS Of 94,939 total cases, diphenhydramine, amitriptyline, bupropion, quetiapine, nortriptyline, and cocaine were most associated with QRS complex prolongation. Inclusion criteria were met by 4,655 cases of exposure to these xenobiotics. QRS complex prolongation was associated with increased odds ratio of seizure in all included xenobiotics, of ventricular dysrhythmia in all included xenobiotics except nortriptyline, and of metabolic acidosis or death in all included xenobiotics except nortriptyline and quetiapine. A normal QRS complex duration had a negative predictive value of greater than or equal to 93.0 percent of developing metabolic acidosis and 98.0 percent of developing a ventricular dysrhythmia or death from the xenobiotics studied. DISCUSSION This study demonstrates that patients with QRS complex prolongation from all six xenobiotics studied had an increased prevalence and odds of developing severe outcomes. Furthermore, patients who did not develop QRS complex prolongation were unlikely to develop a ventricular dysrhythmia, metabolic acidosis, or death. These findings were noted in six xenobiotics that mechanistically can cause QRS complex prolongation through sodium channel or gap junction inhibition. CONCLUSION Identification of patients at risk for severe outcomes after overdose can be aided by measuring the QRS complex duration. If prospectively validated, these outcomes have implications on risk stratification, disposition level of care, and appropriateness of treatments.
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Affiliation(s)
- Mark Simon
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sabrina Kaplan
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Karen Muschler
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
| | - Jeffrey Brent
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
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Hughes AR, Lin A, Hendrickson RG. Clinical and patient characteristics associated with severe outcome in diphenhydramine toxicity. Clin Toxicol (Phila) 2021; 59:918-925. [PMID: 33666139 DOI: 10.1080/15563650.2021.1891244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Diphenhydramine is frequently misused and ingested recreationally for its antihistaminergic and antimuscarinic effects and is often involved in both serious and fatal poisonings, either in isolation or in combination with other xenobiotics. OBJECTIVE This analysis sought to determine which patient and encounter characteristics were associated with severe outcome after diphenhydramine overdose. METHODS This is an analysis of the multi-center ToxIC registry (2010-2016). Descriptive analysis of all cases with diphenhydramine listed as the "primary agent" contributing to toxicity were included. Analysis sought to determine which patient and encounter characteristics were associated with severe outcome, defined as occurrence of seizure, ventricular dysrhythmia, or intubation. To determine which patient and encounter characteristics were individually associated with severe outcome, we performed chi-square tests. Fisher's exact tests were used in the case of sparse data. We also performed multivariable logistic regression to further determine independent risk factors for severe outcome in diphenhydramine overdose. RESULTS Eight hundred and sixty-three cases remained after exclusion with 15.6% (n = 135) of all patients having one or more severe outcome. The most common severe outcome was seizures which occurred in 98 (11.6%) of all ingestions. Females comprised 59.1% (n = 510) of all ingestions. Most ingestions were intentional (86.0%, n = 742) with the most common known reason for an intentional ingestion being self-harm, accounting for 37.5% (n = 324) of all ingestions. Self-harm ingestions and ingestions in males were more commonly associated with intubation. When examining outcomes by age, there were no significant differences overall or in any individual outcome except intubation in which children 0-12 were less likely to be intubated as compared to teens and adults. Signs and symptoms most strongly associated with a severe outcome included acidemia (pH < 7.2), QRS prolongation (QRS > 120 ms), and elevated anion gap (AG > 20). DISCUSSION Acidemia, QRS prolongation, and elevated anion gap are associated with severe outcomes in diphenhydramine toxicity. Further research is warranted to determine their predictive characteristics.
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Affiliation(s)
- Adrienne R Hughes
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.,Oregon Poison Center, Portland, OR, USA
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Robert G Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.,Oregon Poison Center, Portland, OR, USA
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Yang XY, Song XT, Zhang Y. Wide QRS Complex Tachycardia With a Dominant R-Wave in Lead aVR-Is It Ventricular Tachycardia? JAMA Intern Med 2020; 180:1682-1684. [PMID: 32955548 DOI: 10.1001/jamainternmed.2020.4759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Xiao-Yan Yang
- The first affiliated hospital of Hunan normal university, Hunan Provincial People's Hospital, Changsha City, Hunan Province, Changsha, China
| | - Xin-Tian Song
- People's hospital of LaoLing, Dezhou City, Shandong Province, Dezhou, China
| | - Yi Zhang
- The first affiliated hospital of Hunan normal university, Hunan Provincial People's Hospital, Changsha City, Hunan Province, Changsha, China
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4
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You AS, Kalantar-Zadeh K, Streja E, Park C, Sim JJ, Tantisattamo E, Hsiung JT, Obi Y, Potukuchi PK, Amin AN, Nguyen DV, Kovesdy CP, Rhee CM. Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use. Am J Nephrol 2020; 51:715-725. [PMID: 32777779 DOI: 10.1159/000509451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis. METHODS We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007-14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other non-opiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models. RESULTS Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05-1.10), 1.07 (1.01-1.13), and 1.00 (0.94-1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use). CONCLUSIONS In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.
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Affiliation(s)
- Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- University of Washington School of Public Health, Seattle, Washington, USA
| | - John J Sim
- Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA,
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5
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[Acute intoxications: markers for screening, diagnosis and therapy monitoring]. Med Klin Intensivmed Notfmed 2019; 114:302-312. [PMID: 30944942 DOI: 10.1007/s00063-019-0566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/21/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Abstract
Acute poisonings account for a significant proportion of the patient population presenting to intensive care units, whereby mixed drug overdoses and prescription drug overdoses predominate. The aim of this article was to describe indications for screening, diagnosis and therapy monitoring in acute overdoses in the intensive care unit. To conduct this work, a literature search was carried out and a review was written based on guidelines, case reports, expert opinions and scientific publications. Toxidromes are a useful tool for classification of clinical characteristics when the causative agent is initially unknown. Especially in critical care medicine, identifying and quantifying of the causative toxin by enzyme immunoassays, chromatography and mass spectrometry should be attempted. Intensive care treatment of patients with acute overdoses includes not only monitoring and support of vital functions but also methods for primary and secondary elimination of toxins. The indication for the use of extracorporeal procedures should be carefully evaluated and the method should be chosen based on protein binding and molecular size. Lipid emulsion therapy, high-dose insulin euglycaemia therapy and hyperbaric oxygenation are also increasingly used.
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6
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Hu MX, Lamers F, Penninx BWJH, de Geus EJC. Association Between Depression, Anxiety, and Antidepressant Use With T-Wave Amplitude and QT-Interval. Front Neurosci 2018; 12:375. [PMID: 29922124 PMCID: PMC5996116 DOI: 10.3389/fnins.2018.00375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/15/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives: Cardiac repolarization may be affected by psychiatric disorders and/or antidepressant use, but evidence for this is inconclusive. This study examined the relationship between depressive and anxiety disorder and use of antidepressants with T-wave amplitude (TWA) and QT-interval. Methods: Data was obtained from the Netherlands Study of Depression and Anxiety (n = 1,383). Depression/anxiety was diagnosed with the DSM-IV based Composite International Diagnostic Interview. The use of tricyclic antidepressants (TCAs), selective serotonin and noradrenalin reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs) was established. T-wave amplitude and QT-interval corrected for heart rate (QTc) were obtained from an ECG measured in a type II axis configuration. Results: Compared to controls, persons with depression or anxiety disorders did not show a significantly different TWA (p = 0.58; Cohen's d = 0.046) or QTc (p = 0.48; Cohen's d = −0.057). In spite of known sympathomimetic effects, TCA use (p = 0.26; Cohen's d = −0.162) and SNRI use (p = 0.70; Cohen's d = −0.055) were not significantly associated with a lower TWA. TCA use (p = 0.12; Cohen's d = 0.225) and SNRI use (p = 0.11; Cohen's d = 0.227) were also not significantly associated with a prolonged QTc. Conclusion: We did not find evidence that either depressive/anxiety disorder or antidepressant use is associated with abnormalities in TWA or QTc. Earlier found sympathomimetic effects of TCAs and SNRIs are not evident in these measures of cardiac repolarization.
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Affiliation(s)
- Mandy X Hu
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
| | - Femke Lamers
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
| | - Brenda W J H Penninx
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
| | - Eco J C de Geus
- Department of Biological Psychology, VU University, Amsterdam, Netherlands
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7
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Goldstein JN, Dudzinski DM, Erickson TB, Linder G. Case 12-2018: A 30-Year-Old Woman with Cardiac Arrest. N Engl J Med 2018; 378:1538-1549. [PMID: 29669228 DOI: 10.1056/nejmcpc1800322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Joshua N Goldstein
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
| | - David M Dudzinski
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
| | - Timothy B Erickson
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
| | - Grace Linder
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
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8
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Jansen T, Hoegberg LCG, Eriksen T, Haarmark C, Dalhoff K, Belhage B. Advanced Electrocardiogram Analysis in the Amitriptyline-poisoned Pig Treated with Activated Charcoal Haemoperfusion. Basic Clin Pharmacol Toxicol 2017; 122:442-447. [DOI: 10.1111/bcpt.12931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Tejs Jansen
- Department of Anaesthesiology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Lotte C. G. Hoegberg
- Department of Anaesthesiology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical Sciences; Faculty of Health and Medical Sciences; University Hospital for Companion Animals; University of Copenhagen; Copenhagen Denmark
| | - Christian Haarmark
- Department of Clinical Physiology and Nuclear Medicine; Copenhagen University Hospital Herlev and Gentofte; Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Bo Belhage
- Department of Anaesthesiology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
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9
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Sogut O, Yalcin S, Kaya H, Gokdemir MT, Sezen Y. Opipramol Overdose Presented with Wide-Complex Tachycardia to the Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791201900207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Opipramol is an antidepressant and anxiolytic drug similar in structure to tricyclic antidepressants (TCAs) but it is primarily used for the treatment of generalized anxiety disorders. Unlike many TCAs, opipramol has no reuptake-inhibiting properties. Opipramol acts as a high affinity sigma receptor agonist. Opipramol acts as a low to moderate affinity antagonist for the dopamine-2 (D2), 5-hydroxtryptamine (5-HT2), histamine 1 (H1), histamine 2 (H2), and muscarinic acetylcholine receptors accounting for its antihistamine effects, and muscarinic anticholinergic properties. Here, we report a rare case of opipramol overdose case involving a 18-year-old woman, presenting to our emergency department (ED) with loss of consciousness and wide-complex tachycardia. A firm diagnosis of opipramol overdose was made on the basis of clinical, laboratory and electrocardiogram findings.
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Affiliation(s)
| | - S Yalcin
- Harran University, Medical Faculty, Department of Anesthesiology and Reanimation, Sanliurfa, Turkey
| | | | | | - Y Sezen
- Harran University, Medical Faculty, Department of Cardiology, Sanliurfa, Turkey
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10
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Sabah KMN, Chowdhury AW, Islam MS, Saha BP, Kabir SR, Kawser S. Amitriptyline-induced ventricular tachycardia: a case report. BMC Res Notes 2017; 10:286. [PMID: 28709467 PMCID: PMC5513042 DOI: 10.1186/s13104-017-2615-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 07/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background In Bangladesh, each emergency physician faces amitriptyline overdose nearly a day. An acute cardiovascular complication, one of the worst complications is mainly responsible for the mortality in tricyclic overdose. Recently, we managed ventricular tachycardia in a young female presented with an impaired consciousness 10 h after intentionally ingesting 2500 mg amitriptyline. Here, we report it, discuss how the electrocardiography is vital to acknowledge and predict it and its’ complications and also the recent update of the management of it. Case presentation A young married Bangladeshi-Bengali girl, 25-year-old, having a history of disharmony with her husband, came with an impaired consciousness after intentionally ingesting 2500 mg amitriptyline about 10 h before arrival. There was blood pressure 140/80 mmHg, heart rate 140 beats-per-min, temperature 103 °F, Glasgow coma scale 10/15, wide complex tachycardia with QRS duration of 178 ms in electrocardiography, blood pH 7.36. Initially, treated with 100 ml 8.4% sodium bicarbonate. After that, QRS duration came to 100 ms in electrocardiography within 10 min of infusion. To maintain the pH 7.50–7.55 over the next 24 h, the infusion of 8.4% sodium bicarbonate consisting of 125 ml dissolved in 375 ml normal saline was started and titrated according to the arterial blood gas analysis. Hence, a total dose of 600 mmol sodium bicarbonate was given over next 24 h. In addition to this, gave a 500 ml intravenous lipid emulsion over 2 h after 24 h of admission as she did not regain her consciousness completely. Afterward, she became conscious, though, in electrocardiography, ST/T wave abnormality persisted. So that, we tapered sodium bicarbonate infusion slowly and stopped it later. At the time of discharge, she was by heart rate 124/min, QRS duration 90 ms in electrocardiogram along with other normal vital signs. Conclusion Diagnosis of amitriptyline-induced ventricular tachycardia is difficult when there is no history of an overdose obtained. Nevertheless, it should be performed in the clinical background and classic electrocardiographic changes and wise utilization of sodium bicarbonate, intravenous lipid emulsion, and anti-arrhythmic drugs may save a life.
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Affiliation(s)
| | | | | | | | | | - Shamima Kawser
- Dr. Sirajul Islam Medical College & Hospital Ltd, Dhaka, Bangladesh
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11
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Jansen T, Petersen H, Malskaer CM, Gabel-Jensen C, Dalhoff K, Eriksen T, Belhage B, Hoegberg LCG. Activated Charcoal Haemoperfusion in the Treatment of Experimental Amitriptyline Poisoning in Pigs - The Effect on Amitriptyline Plasma Concentration and Haemodynamic Parameters. Basic Clin Pharmacol Toxicol 2017; 120:491-497. [PMID: 27863000 DOI: 10.1111/bcpt.12704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/06/2016] [Indexed: 12/15/2022]
Abstract
Coated activated charcoal haemoperfusion (CAC-HP) is a well-known treatment modality. Case reports have revealed conflicting results about the efficacy of CAC-HP in the treatment of amitriptyline (AT) poisoning, and no randomized clinical trials have been identified in the literature. This study aimed at quantifying the efficacy of modern CAC-HP as an adjunctive treatment of AT intoxication compared with standard care alone. Fourteen female Danish landrace pigs were randomized to either standard care or standard care plus 4 hr of CAC-HP. The pigs were anaesthetized, and vital parameters were continuously recorded. Amitriptyline infusion (7.5 mg/kg) was completed in 20 min. Thirty minutes after AT infusion, activated charcoal was instilled orally in both groups. In the intervention group, CAC-HP was initiated 60 min. after AT infusion. Blood and urine samples were collected as were vital parameters at specific time intervals. The protocol was approved by the Danish Experimental Animal Expectorate and complied with the NIH guide for care and use of laboratory animals. Data were managed according to the ARRIVE guidelines. No statistical significant differences between intervention and control groups were found when analysing for differences in AT levels in plasma at any time-point. Furthermore, significant differences between the control and intervention groups in regard to vital parameters could not be found either. In our animal model, the addition of CAC-HP did not improve the clearance of AT compared with standard treatment alone. We suggest that the effect of modern CAC-HP as a treatment modality in AT-poisoned human patients may be inadequate.
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Affiliation(s)
- Tejs Jansen
- Department of Anaesthesiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Henrik Petersen
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie M Malskaer
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Gabel-Jensen
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinic and Animal Sciences, University Hospital for Companion Animals, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Belhage
- Department of Anaesthesiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Lotte C G Hoegberg
- Department of Anaesthesiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
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12
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Manini AF, Nair AP, Vedanthan R, Vlahov D, Hoffman RS. Validation of the Prognostic Utility of the Electrocardiogram for Acute Drug Overdose. J Am Heart Assoc 2017; 6:e004320. [PMID: 28159815 PMCID: PMC5523748 DOI: 10.1161/jaha.116.004320] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 12/01/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND While it is certain that some emergency department patients with acute drug overdose suffer adverse cardiovascular events (ACVE), predicting ACVE is difficult. The prognostic utility of the ECG for heterogeneous drug overdose patients remains to be proven. This study was undertaken to validate previously derived features of the initial ECG associated with ACVE in this population. METHODS AND RESULTS We performed a prospective validation cohort study to evaluate adult emergency department patients with acute drug overdose at 2 urban university hospitals over 5 years in whom an emergency department admission ECG was performed. Exclusion criteria were alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. ACVE was defined as any of the following: circulatory shock, myocardial injury, ventricular dysrhythmia, or cardiac arrest. Blinded cardiologists interpreted ECGs for previously derived predictors of ACVE (ectopy, QT prolongation, nonsinus rhythm, ischemia/infarction), QT dispersion, and prominent R wave in lead AVR. Of 589 patients who met inclusion criteria (48% male, mean age 42), there were 95 ACVEs (39 shock, 64 myocardial injury, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were as follows: benzodiazepines, opioids, and acetaminophen. Previously derived criteria were highly predictive of ACVE, with QT correction >500 ms as the highest risk feature (OR 11.2, CI 4.6-27). CONCLUSIONS This study confirms that early ECG evaluation is essential to assess the cardiovascular prognosis and medical clearance of emergency department patients with acute drug overdose. Furthermore, this study validates previously derived high-risk features of the admission ECG to risk stratify for ACVE in this patient population.
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Affiliation(s)
- Alex F Manini
- Division of Medical Toxicology, Elmhurst Hospital Center, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ajith P Nair
- Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Rajesh Vedanthan
- Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - David Vlahov
- Office of the Dean, School of Nursing, University of California, San Francisco, CA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY
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Unverir P, Atilla R, Karcioglu O, Topacoglu H, Demiral Y, Tuncok Y. A retrospective analysis of antidepressant poisonings in the emergency department: 11-year experience. Hum Exp Toxicol 2016; 25:605-12. [PMID: 17165627 DOI: 10.1177/096032706072470] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Between 1993 and 2004, patients with antidepressant poisoning admitted to an emergency department (ED) were analysed retrospectively with regard to demographics, clinical findings and treatment attempts. Age, gender, suicide attempts, classification of antidepressants, Glasgow Coma Scale (GCS) score, ECG findings, need for endotracheal intubation, follow-up period and Antidepressant Overdose Risk Assessment (ADORA) criteria were analysed by SPSS software. A total of 356 antidepressant poisoning cases were evaluated. Tricyclic antidepressants (TCA), especially opipramol and amitriptyline, were the most common agents (58.4%). The most frequent ECG finding was sinus tachycardia (40.7%, n=145). Endotracheal intubation was required in 9.6% of cases. Patients with TCA ingestion had a longer observation time in the ED, abnormal ECG findings, abnormal physical examination findings and more ADORA criteria, than patients who ingested selective serotonin re-uptake inhibitors (SSRI) (P=0.008, P=0.008, P<0.001, P<0.001). It was found that the patients who ingested TCA (P=0.001), poisoned with amitriptyline (P=0.001), patients with GCS scores of 8 and less (P=0.001), patients with two or more ADORA criteria (P=0.001), with seizures (P=0.001), with abnormal ECG (P=0.012), and patients with a history of two or more suicide attempts were intubated more frequently. Suicide attempts, classification of the antidepressant, ECG findings, seizure, GCS score and number of detected ADORA criteria affect the need for intubation in patients with antidepressant poisoning.
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Affiliation(s)
- P Unverir
- Department of Emergency Medicine, Dokuz Eylul University School of Medicine, Izmir, Turkey
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Abstract
Although newer cyclic antidepressants have been introduced over the past several years, the tricyclic antidepressants (TCAs) continue to be the leading cause of morbidity from drug overdose in the United States. Overdose features depend on the particular cyclic antidepressant ingested and its pharmacological properties, and can include CNS depression, cardiac arrhythmias, hypotension, seizures, and anticholinergic symptomatology. Life-threatening symptomatology almost always begins within 2 hours, and certainly within 6 hours, after arrival to the emergency department. Plasma TCA levels are unreliable predictors of TCA toxicity and are not recommended. An ECG with a prolonged QRS complex more than 100 msec seems to be the best indicator of serious sequelae with TCAs. Management consists of stabilization of vital signs, gastrointestinal decontamination, intravenous sodium bicarbonate, and supportive care. Agents once thought to be useful for the treatment of cardiac dysrhythmias and seizures such as phenytoin and physostigmine should be avoided. The future of TCA antibody fragments in the treatment of TCA overdose seems promising. Newer and, to some degree, safer antidepressants in overdose have recently been introduced, and they include fluoxetine, trazodone, and sertraline. Amoxapine, bupropion, and maprotiline seem to be as toxic as the TCAs. A significant interaction between cyclic antidepressants and monoamine-oxidase inhibitors exists. Management includes supportive care and basic poison management. Prevention of poisoning seems to be the most logical and effective method of maintaining patient safety. TCAs should be avoided in children younger than 6 years old. All adults with suicidal ideations should receive no more than a 1-week supply (about 1 g) of drug. Finally consideration should be given to using one of the newer, safer antidepressants in all patients with suicidal ideations.
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Affiliation(s)
- Henry Cohen
- Arnold and Marie Schwartz College of Pharmacy, Long Island University, Bellevue Hospital Center
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15
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Clark S, Catt JW, Caffery T. Rapid diagnosis and treatment of severe tricyclic antidepressant toxicity. BMJ Case Rep 2015; 2015:bcr-2015-211428. [PMID: 26468220 DOI: 10.1136/bcr-2015-211428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A woman in her mid-50s contacted her social worker and expressed intent to commit suicide by ingesting prescription medications. On arrival of emergency responders, the patient was found unconscious with an empty bottle of amitriptyline. Time of ingestion was estimated using the social worker's contact with local authorities. The patient's presentation at the emergency department (ED) exemplified tricyclic antidepressant toxidrome with a poor prognosis, based on measurable criteria and physical findings. Respiratory and cardiovascular collapse was managed emergently. Haemodynamic status and EKG findings responded in a stepwise fashion with therapy in the ED and intensive care unit. Full clinical recovery took 7 days, and the patient was subsequently transferred to an in-patient psychiatric facility for further evaluation. Eight days later, she was discharged home with no neurological sequelae.
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Affiliation(s)
- Simon Clark
- Emergency Medicine Residency Program-Baton Rouge, Louisiana State University Health Sciences Center School of Medicine in New Orleans, Baton Rouge, Louisiana, USA
| | - Jerry W Catt
- Emergency Medicine Residency Program-Baton Rouge, Louisiana State University Health Sciences Center School of Medicine in New Orleans, Baton Rouge, Louisiana, USA
| | - Terrell Caffery
- Emergency Medicine Residency Program-Baton Rouge, Louisiana State University Health Sciences Center School of Medicine in New Orleans, Baton Rouge, Louisiana, USA
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16
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Paksu S, Duran L, Altuntas M, Zengin H, Salis O, Ozsevik SN, Albayrak H, Murat N, Guzel A, Paksu MS. Amitriptyline overdose in emergency department of university hospital: evaluation of 250 patients. Hum Exp Toxicol 2014; 33:980-90. [PMID: 24505046 DOI: 10.1177/0960327113520019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the patients with acute amitriptyline poisoning and investigate predictive factors for the development of life-threatening complications. METHODS Demographics, clinical, laboratory, and electrocardiographic (ECG) findings of 250 patients were evaluated retrospectively. Predictive parameters for the development of serious complications were studied. RESULTS Median age of patients was 14.6 years, of which, 70% of patients were female and 66% were in pediatric age group. The most common pathological clinical finding and laboratory abnormality were alteration of consciousness and hyponatremia. The rate of convulsive seizure, arrhythmia, and respiratory depression were 17 (6.8%), 16 (6.4%), and 11 (4.4%), respectively. These complications were more seen in pediatric patients than adults (15.8% and 1.2%). The incidence of hyponatremia was more in pediatric patients and severe poisoning groups (38.8 and 53.4%, respectively). The levels of amitriptyline and nortriptyline were significantly higher in the group with complications than the group without complications (p < 0.05). All adult patients were discharged with good prognosis. In pediatric age group, one patient was discharged with severe neurological sequelae and one patient died. QRS duration >100 ms, long corrected QT duration interval, and low Glasgow Coma Score (GCS) at admission were identified as independent risk factors for the development of life-threatening complications (odds ratio: 69.4, 1.9, and 1383, respectively; p < 0.05). CONCLUSION Amitriptyline poisoning may be associated with life-threatening complications, especially in pediatric age group and in patients with hyponatremia. Low GCS, presence of hyponatremia, high serum drug levels, and pathological ECG findings on admission may be helpful in predicting the development of complications and poor prognosis.
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Affiliation(s)
- S Paksu
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - L Duran
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - M Altuntas
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - H Zengin
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - O Salis
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - S N Ozsevik
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - H Albayrak
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - N Murat
- Department of Industrial Engineering, Faculty of Engineering, Ondokuz Mayis University, Samsun, Turkey
| | - A Guzel
- Department of Pediatric Emergency, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - M S Paksu
- Pediatric Intensive Care Unit, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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17
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Jang DH, Spyres MB, Fox L, Manini AF. Toxin-Induced Cardiovascular Failure. Emerg Med Clin North Am 2014; 32:79-102. [DOI: 10.1016/j.emc.2013.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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18
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Crack cocaine-induced cardiac conduction abnormalities are reversed by sodium bicarbonate infusion. Case Rep Med 2013; 2013:396401. [PMID: 23762070 PMCID: PMC3677010 DOI: 10.1155/2013/396401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 05/13/2013] [Indexed: 12/27/2022] Open
Abstract
We report a dramatic case of a 19-year-old man with crack cocaine overdose with important clinical complications as cardiac arrest due to ventricular fibrillation and epileptics status. During this intoxication, electrocardiographic abnormalities similar to those found in tricyclic antidepressant poisoning were observed, and they were reversed by intravenous sodium bicarbonate infusion.
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19
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Yates C, Manini AF. Utility of the electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Curr Cardiol Rev 2013; 8:137-51. [PMID: 22708912 PMCID: PMC3406273 DOI: 10.2174/157340312801784961] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 06/12/2011] [Accepted: 07/02/2011] [Indexed: 11/22/2022] Open
Abstract
The ECG is a rapidly available clinical tool that can help clinicians manage poisoned patients. Specific myocardial effects of cardiotoxic drugs have well-described electrocardiographic manifestations. In the practice of clinical toxicology, classic ECG changes may hint at blockade of ion channels, alterations of adrenergic tone, or dysfunctional metabolic activity of the myocardium. This review will offer a structured approach to ECG interpretation in poisoned patients with a focus on clinical implications and ECG-based management recommendations in the initial evaluation of patients with acute cardiotoxicity.
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Affiliation(s)
- Christopher Yates
- Emergency Medicine Department / Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain.
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20
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Zimmerman T, Beuhler MC, Kerns W. Is nurse interpretation of the ECG QRS width reliable? J Med Toxicol 2012; 8:140-4. [PMID: 22215289 DOI: 10.1007/s13181-011-0205-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Electrocardiogram (ECG) data are critical in formulating management strategies following sodium channel antagonist overdose. Poison centers frequently rely on verbal reports of the ECG obtained from bedside nurses. No previous study has addressed the quality of ECG data obtained in this manner. Therefore, we sought to test the ability of nurses to recognize and measure a widened QRS complex, the hallmark of myocardial sodium channel toxicity. Thirty-six emergency department and critical care nurses employed at a tertiary care hospital participated in this prospective study. The study subjects were divided into three groups and asked to interpret 12 ECGs (five normal and seven wide QRS). For each ECG, participants (1) determined if the QRS was narrow or wide and (2) measured the QRS duration. The groups differed in delivery of instruction regarding QRS measurement. Group 1 received visual instructions; group 2 received scripted verbal instructions, and group 3 served as controls, receiving no specific QRS measurement instructions. The nurse data was compared with physician interpretation (consensus of three physicians). Between-group analysis tested for impact of potential real-time educational intervention. Overall, the nurses identified a wide QRS complex most of the time (77%), but had difficulty in accurately measuring the QRS duration (44%). Real-time visual or verbal instruction did not improve accuracy (p = NS between groups). The results suggest that verbal ECG data from nurse callers is not sufficient to make an accurate clinical assessment in the setting of sodium channel poisoning.
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21
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Emamhadi M, Sanaei-Zadeh H, Nikniya M, Zamani N, Dart RC. Electrocardiographic manifestations of tramadol toxicity with special reference to their ability for prediction of seizures. Am J Emerg Med 2012; 30:1481-5. [DOI: 10.1016/j.ajem.2011.12.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/09/2011] [Accepted: 12/09/2011] [Indexed: 12/01/2022] Open
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22
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The first published case of a pediatric diphenhydramine overdose whose electrocardiogram shows terminal 40-millisecond frontal-plane QRS axis deviation. Pediatr Emerg Care 2012; 28:730. [PMID: 22766599 DOI: 10.1097/pec.0b013e31825d2de9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Sanaei-Zadeh H. Comment on "Serial monitoring of lead aVR in patients with prolonged unconsciousness following tricyclic antidepressant overdose". Psychiatry Investig 2012; 9:85-6. [PMID: 22396691 PMCID: PMC3285748 DOI: 10.4306/pi.2012.9.1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 09/09/2011] [Accepted: 09/27/2011] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hossein Sanaei-Zadeh
- Department of Forensic Medicine and Toxicology, Tehran University of Medical Sciences, Hazrat Rasoul Akram Hospital, Tehran-IRAN
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24
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Sanaei-Zadeh H, Zamani N, Shahmohammadi F. Methods for the measurement of the terminal 40-millisecond (T40-ms) frontal plane axis in tricyclic antidepressant poisoning. Resuscitation 2011; 82:1255-6. [DOI: 10.1016/j.resuscitation.2011.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 05/18/2011] [Indexed: 11/24/2022]
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25
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Hoffman RS. Treatment of patients with cocaine-induced arrhythmias: bringing the bench to the bedside. Br J Clin Pharmacol 2011; 69:448-57. [PMID: 20573080 DOI: 10.1111/j.1365-2125.2010.03632.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Widespread use of cocaine and its attendant toxicity has produced a wealth of benchwork studies and small animal investigations that evaluated the effects of cocaine on the cardiovascular system. Despite this wealth of knowledge, very little is known about the frequency or types of arrhythmias in patients with significant cocaine toxicity. The likely aetiologies; catecholamine excess, sodium channel blockade, potassium channel blockade, calcium channel effects, or ischaemia may act alone or in concert to produce a vast array of clinical findings that are modulated by hyperthermia, acidosis, hypoxia and electrolyte abnormalities. The initial paper in the series by Wood & Dargan providing the epidemiological framework of cocaine use and abuse is followed by a detailed review of the electrophysiological effects of cocaine by O'Leary & Hancox. This review is designed to complement the previous papers and focuses on the diagnosis and treatment of patients with cocaine-associated arrhythmias.
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26
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Inaccuracy of ECG Interpretations Reported to the Poison Center. Ann Emerg Med 2011; 57:122-7. [DOI: 10.1016/j.annemergmed.2010.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 08/13/2010] [Accepted: 09/15/2010] [Indexed: 11/21/2022]
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27
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Jang DH, Manini AF, Trueger NS, Duque D, Nestor NB, Nelson LS, Hoffman RS. Status epilepticus and wide-complex tachycardia secondary to diphenhydramine overdose. Clin Toxicol (Phila) 2011; 48:945-8. [PMID: 21171853 DOI: 10.3109/15563650.2010.527850] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Diphenhydramine is an H1 histamine antagonist that is commonly used for allergic reactions, colds and cough, and as a sleep aid. In addition to anticholinergic and antihistaminergic effects, sodium channel blockade becomes evident following diphenhydramine overdose. While seizures may occur following overdose of a diphenhydramine, status epilepticus is distinctly uncommon. We report a case with both status epilepticus and wide-complex dysrhythmias following an intentional diphenhydramine overdose. CASE REPORT A 36-year-old woman with a medical history of hypothyroidism on levothyroxine was brought to the emergency department with active seizures by emergency medical services after what was later determined to be a diphenhydramine overdose. One hour after an argument with her husband he found her lethargic in a locked room. Initial vital signs were: blood pressure, 90/55 mmHg; heart rate, 160 beats/min; respiratory rate 18 breaths/min; room air oxygen saturation, 99%; temperature, 99.8°F; rapid point-of-care glucose, 130 mg/dL. The generalized seizures continued for duration of 30 min, despite the intravenous administration of 8 mg of lorazepam. The patient underwent endotracheal intubation and a propofol infusion terminated her seizures. An electrocardiogram after the status was terminated which revealed a wide-complex tachycardia with QRS duration of 127 ms. The QRS narrowed after 200 mEq of intravenous sodium bicarbonate was administrated. The patient was neurologically intact upon extubation on hospital day 2. The serum diphenhydramine concentration drawn on arrival to the ED was 1200 ng/mL (9-120 ng/mL); a tricyclic screen was negative. DISCUSSION While seizures and sodium channel blockade are recognized complications of diphenhydramine toxicity, reported cases of status epilepticus from diphenhydramine overdose are rare. Elements of the patient's presentation were similar to a tricyclic overdose and management required aggressive control of her seizures, sodium bicarbonate therapy, and recognizing that physostigmine was contraindicated due to wide complex tachycardia. CONCLUSIONS Diphenhydramine overdose may cause status epilepticus and wide-complex tachycardia. Management should focus on antidotal therapy with sodium bicarbonate and supportive neurological management with appropriate anticonvulsants and airway protection if clinically indicated.
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Affiliation(s)
- David H Jang
- New York University School of Medicine, New York, NY 10016, USA.
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28
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Electrocardiographic predictors of adverse cardiovascular events in suspected poisoning. J Med Toxicol 2010; 6:106-15. [PMID: 20361362 DOI: 10.1007/s13181-010-0074-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Poisoning is the second leading cause of injury-related fatality in the USA and the leading cause of cardiac arrest in victims under 40 years of age. The study objective was to define the electrocardiographic (ECG) predictors of adverse cardiovascular events (ACVE) complicating suspected acute poisoning (SAP). This was a case-control study in adults at three tertiary-care hospitals and one regional Poison Control Center. We compared 34 cases of SAP complicated by ACVE to 101 consecutive control patients with uncomplicated SAP. The initial ECG was analyzed for rhythm, intervals, QT dispersion, ischemia, and infarction. ECGs were interpreted by a cardiologist, blinded to study hypothesis and case data. Subjects were 48% male, with mean age 42 +/- 19 years. In addition to clinical suspicion of poisoning in 100% of patients, routine toxicology screens were positive in 77%, most commonly for benzodiazepines, opioids, and/or acetaminophen. Neither the ventricular rate, the QRS duration, nor the presence of infarction predicted the risk of ACVE. However, the rhythm, QTc, QT dispersion, and presence of ischemia correlated with the risk of ACVE. Independent predictors of ACVE based on multivariable logistic regression were prolonged QTc, any non-sinus rhythm, ventricular ectopy, and ischemia. Recursive partitioning analysis identified very low risk criteria (94.1% sensitivity, 96.2% NPV) and high risk criteria (95% specificity). Among patients with SAP, the presence of QTc prolongation, QT dispersion, ventricular ectopy, any non-sinus rhythm, and evidence of ischemia on the initial ECG are strongly associated with ACVE.
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29
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Lim BL, Vasu A, Lim GH. Evaluating the Role of a Triage Electrocardiogram Protocol at an Urban Emergency Department. HONG KONG J EMERG ME 2010. [DOI: 10.1177/102490791001700207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Our emergency department (ED) performs triage ECG for a variety of complaints to identify patients in need of treatment escalation. The aim of this study was to evaluate the existing triage ECG protocol as a means of treatment decision making. Methods This prospective observational study was conducted in an urban ED over one week. We recruited all patients aged 18 years and above with an undiagnosed complaint requiring a triage ECG based on the existing departmental protocol. As part of the protocol, an experienced emergency doctor then reviewed the ECG to determine the need for treatment escalation. Explicit data collection was performed using our electronic database. The outcome measures were proportions of triage treatment escalations, reasons for escalation and disposition status. Analysis was by descriptive statistics. Results 739 patients were recruited from a total attendance of 3228. The rate of triage ECG was 23%. There were 22 (3%) triage escalations. Usually each escalation resulted from a combination of reasons. These included important ECG changes (77%), abnormal vital signs (5%) and ongoing symptoms (95%). Conclusions The triage ECG protocol resulted in important escalations in a small proportion of presentations. Future research is needed to refine guidelines on the use of triage ECG for different ED complaints.
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Açikalin A, Satar S, Avci A, Topal M, Kuvandk G, Sebe A. QTc intervals in drug poisoning patients with tricyclic antidepressants and selective serotonin reuptake inhibitors. Am J Ther 2010; 17:30-3. [PMID: 19417591 DOI: 10.1097/mjt.0b013e318197eec6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Commonly used agents of drug poisoning among patients who come to the emergency services are tricyclic antidepressants (TCAs). These drugs may cause defect in cardiac conduction due to the slowdown in the cardiac depolarization and expansions in the QT interval. Selective serotonin reuptake inhibitors (SSRIs) are less expansion of the QT period and lower cardio toxic side effects. The aim of this study was to investigate QTc intervals and prognosis of the patients who come to the emergency service due to TCA and SSRI group antidepressant drug poisoning. In a study of 96 patients, 75 of whom were diagnosed to be poisoned by TCAs (TCA group) and 21 by SSRIs (SSRI group) were examined. Electrocardiographic alterations and QTc intervals all of patients were evaluated. QTc intervals of patients in TCA group were determined to be slightly more than those in SSRI group and it was not statistically significant. In the SSRI group, only one patient had QTc period more than 500 milliseconds (520 milliseconds); however, TCA overdose showed 9 (12%) patients with QTc interval over 500 milliseconds, and QTc values of 2 patients were over 600 milliseconds. In our study, it was determined that SSRI group drugs caused similar expansion of the QTc period as TCA drugs but they did not reach high values like TCA drugs, and their OTc intervals stayed in more innocent levels.
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Affiliation(s)
- Ayça Açikalin
- Gaziantep Aralik Hospital, Department of Emergency Medicine, Turkey.
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31
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Abstract
The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life support--airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). These may include syrup of ipecac, orogastric lavage, activated single- or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). Pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. In the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, N-acetylcysteine, physostigmine, L-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. In summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. Data supporting antidotes effectiveness vary considerably. Clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases.
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Affiliation(s)
- Silas W Smith
- New York City Poison Control Center, New York University School of Medicine, New York, USA.
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32
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Eyer F, Stenzel J, Schuster T, Felgenhauer N, Pfab R, von Bary C, Zilker T. Risk assessment of severe tricyclic antidepressant overdose. Hum Exp Toxicol 2009; 28:511-9. [DOI: 10.1177/0960327109106970] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prognostic factors for severe complications in tricyclic antidepressant (TCA) overdose remain unclear. We therefore evaluated the value of clinical characteristics and electrocardiograph (ECG) parameters to predict serious events (seizures, arrhythmia, death) in severe TCA overdose of 100 patients using logistic regression models for risk assessment. The overall fatality rate was 6%, arrhythmia occurred in 21% and 31% of the patients developed seizures. Using an univariable logistic regression model, the maximal QRS interval (OR 1.22; 95% CI 1.06-1.41; p = .005), the time lag between ingestion and occurrence of first symptoms of overdose (OR 1.13; 95% CI 0.99-1.29; p = .072) and the age (OR 0.73; 95% CI 0.55-0.98; p = .038) were determined as the solely predictive parameters. In the multivariable logistic regression model, the QRS interval could not be established as independent predictor, however, the terminal 40-ms frontal plane QRS vector (T40) reached statistical significance regarding prediction of serious events (odds ration [OR] 1.70; 95% confidence interval [CI] 1.02-2.84; p = .041), along with age and time lag between ingestion and onset of symptoms of overdose with a sensitivity and specificity of 71% and 70%, respectively. Evaluation of both clinical characteristics and ECG-parameters in the early stage of TCA overdose may help to identify those patients who urgently need further aggressive medical observation and management.
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Affiliation(s)
- Florian Eyer
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany,
| | - Jochen Stenzel
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Tibor Schuster
- Institute for Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Norbert Felgenhauer
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Rudi Pfab
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Christian von Bary
- Deutsches Herzzentrum München, 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Lazarettstrasse 36, D-80636 Munich, Germany
| | - Thomas Zilker
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
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Wong J, Traub SJ, Macnow L, Kulchycki LK. Altered mental status. J Emerg Med 2008; 35:445-8. [PMID: 18835511 DOI: 10.1016/j.jemermed.2008.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 08/25/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Jason Wong
- Department of Emergency Medicine, Jefferson Regional Medical Center, Pittsburgh, Pennsylvania, USA
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Woolf AD, Erdman AR, Nelson LS, Caravati EM, Cobaugh DJ, Booze LL, Wax PM, Manoguerra AS, Scharman EJ, Olson KR, Chyka PA, Christianson G, Troutman WG. Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2008; 45:203-33. [PMID: 17453872 DOI: 10.1080/15563650701226192] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B). 4) Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department: an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose. For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5 mg/kg. For despiramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; and for protriptyline it is >1 mg/kg. This recommendation applies to both patients who are naïve to the specific TCA and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grades B/C). 5) Do not induce emesis (Grade D). 6) The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D). 7) For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C). 8) Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D). 9) An ECG or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B). 10) Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard ACLS guidelines (Grade D). 11) Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D). 12) For TCA-associated convulsions, benzodiazepines are recommended (Grade D). 13) Flumazenil is not recommended for patients with TCA poisoning (Grade D).
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Affiliation(s)
- Alan D Woolf
- American Association of Poison Control Centers, Washington, District of Columbia, USA
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Afshari R, Maxwell S, Dawson A, Bateman DN. ECG Abnormalities in Co-proxamol (Paracetamol/Dextropropoxyphene) Poisoning. Clin Toxicol (Phila) 2008. [DOI: 10.1081/clt-66069] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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36
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Abstracts of the European Association of Poisons Centres and Clinical Toxicologists XXV International Congress. Clin Toxicol (Phila) 2008. [DOI: 10.1080/07313820500207624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Chan HY, Chan YC, Lau FL. Reversal of Brugada electrocardiographic pattern with sodium bicarbonate solution after amitriptyline overdose. Clin Toxicol (Phila) 2008; 46:892-6. [PMID: 18788005 DOI: 10.1080/15563650802293984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A Brugada electrocardiographic pattern (BEP) associated with tricyclic antidepressant (TCA) overdose has been reported rarely, but its reversal by sodium bicarbonate has not been described previously. We reported a case of amitriptyline overdose induced Type 1 BEP which was reversed by 150 mEq of intravenous sodium bicarbonate.
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Affiliation(s)
- Ho Yin Chan
- Hong Kong Poison Information Centre, Hong Kong.
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Bebarta VS, Phillips S, Eberhardt A, Calihan KJ, Waksman JC, Heard K. Incidence of Brugada electrocardiographic pattern and outcomes of these patients after intentional tricyclic antidepressant ingestion. Am J Cardiol 2007; 100:656-60. [PMID: 17697824 DOI: 10.1016/j.amjcard.2007.03.077] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 03/13/2007] [Accepted: 03/13/2007] [Indexed: 10/23/2022]
Abstract
Brugada syndrome is a genetic dysfunction of the myocardial sodium channel that leads to ventricular dysrhythmias. The electrocardiographic (ECG) pattern of Brugada syndrome is occasionally seen after tricyclic antidepressant (TCA) ingestion; however, the outcome and complication risk for these patients is not clear. The objective of our study was to describe the incidence of Brugada ECG pattern (BEP) and serious complications of these patients in a large case series of intentional TCA ingestions. We also compared the proportion of complications of patients with BEP versus those without BEP. We evaluated 402 TCA ingestions, of which 9 (2.3%) were associated with the development of BEP. We compared the adverse outcomes of all TCA ingestions versus TCA ingestions with BEP. A increase in the adverse outcomes in the BEP group was found: seizures (relative risk [RR] 4; 95% confidence interval [CI] 1.5 to 10.8), widened QRS (RR 4.8; 95% CI 1.8 to 12.9), and hypotension (RR 3.9; 95% CI 2.1 to 7.4). To reduce confounding ingestants, we also compared all patients with an isolated TCA ingestion versus those with BEP. A significant increase in adverse outcomes was again found with the BEP group: seizures (RR 3; 95% CI 1.1 to 8.6), widened QRS (RR 4.8; 95% CI 1.5 to 15.1), and hypotension (RR 3.4; 95% CI 1.9 to 22.3). No deaths or dysrhythmias were found in the BEP group. In conclusion, BEP after TCA ingestion is rare, and death or dysrhythmias did not occur. However, patients with BEP are likely at increased risk for TCA-induced complications.
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Affiliation(s)
- Vikhyat S Bebarta
- Division of Medical Toxicology, Department of Emergency Medicine, Wilford Hall Medical Center, San Antonio, Texas, USA.
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39
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Glancy DL, Glancy CF. Wide Qrs Tachycardia in a Young Woman with a Drug Overdose. Proc (Bayl Univ Med Cent) 2007; 20:305-6. [PMID: 17637887 PMCID: PMC1906582 DOI: 10.1080/08998280.2007.11928309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- D Luke Glancy
- Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA.
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Abstract
Tricyclic antidepressants remain a common cause of fatal drug poisoning as a result of their cardiovascular toxicity manifested by ECG abnormalities, arrhythmias and hypotension. Dosulepin and amitriptyline appear to be particularly toxic in overdose. The principal mechanism of toxicity is cardiac sodium channel blockade, which increases the duration of the cardiac action potential and refractory period and delays atrioventricular conduction. Electrocardiographic changes include prolongation of the PR, QRS and QT intervals, nonspecific ST segment and T wave changes, atrioventricular block, right axis deviation of the terminal 40 ms vector of the QRS complex in the frontal plane (T 40 ms axis) and the Brugada pattern (downsloping ST segment elevation in leads V1-V3 in association with right bundle branch block). Maximal changes in the QRS duration and the T 40 ms axis are usually present within 12 hours of ingestion but may take up to a week to resolve. Sinus tachycardia is the most common arrhythmia due to anticholinergic activity and inhibition of norepinephrine uptake by tricyclic antidepressants but bradyarrhythmias (due to atrioventricular block) and tachyarrhythmias (supraventricular and ventricular) may occur. Torsade de pointes occurs uncommonly. Hypotension results from a combination of reduced myocardial contractility and reduced systemic vascular resistance due to alpha-adrenergic blockade. Life-threatening arrhythmias and death due to tricyclic antidepressant poisoning usually occurs within 24 hours of ingestion. Rapid deterioration is common. Level of consciousness at presentation is the most sensitive clinical predictor of serious complications. Although a QRS duration >100 ms and a rightward T 40 ms axis appear to be better predictors of cardiovascular toxicity than the plasma tricyclic drug concentration, they have at best moderate sensitivity and specificity for predicting complications.
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Affiliation(s)
- H K Ruben Thanacoody
- Wolfson Unit of Clinical Pharmacology, School of Clinical and Laboratory Sciences, University of Newcastle, and National Poisons Information Service (Newcastle Centre), Newcastle upon Tyne, UK
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Bailey B, Buckley NA, Amre DK. A Meta‐Analysis of Prognostic Indicators to Predict Seizures, Arrhythmias or Death After Tricyclic Antidepressant Overdose. ACTA ACUST UNITED AC 2004; 42:877-88. [PMID: 15533027 DOI: 10.1081/clt-200035286] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To systematically review and summarize studies on the accuracy of ECG and tricyclic antidepressant (TCA) concentration as prognostic indicators of the risk of seizures, ventricular arrhythmia (VA) or death in patients with TCA overdose. METHODS Articles were identified with MedLine and Cochrane register of controlled clinical trials searches and review of medical toxicology textbooks. Quality of the included studies was assessed. Pooled estimates of sensitivity, specificity, likelihood ratios and Summary Receiver Operating Characteristics (SROC) curves were generated. RESULTS A total of 18 studies were included in the analysis. The pooled sensitivity (Se) and specificity (Sp) of the QRS for predicting seizures were 0.69 [95% CI 0.57-0.78] and 0.69 [95% CI 0.58-0.78] as compared to 0.75 [95% CI 0.61-0.85] and 0.72 [95% CI 0.61-0.81] for the TCA concentration. The Se and Sp of the QRS to predict VA were 0.79 [95% CI 0.58-0.91] and 0.46 [95% CI 0.35-0.59] compared to 0.78 [95% CI 0.56-0.90] and 0.57 [95% CI 0.46-0.67] for the TCA concentration. The Se and Sp of the QRS to predict death were 0.81 [95% CI 0.54-0.94] and 0.62 [95% CI 0.55-0.68] compared to 0.76 [95% CI 0.49-0.91] and 0.60 [95% CI 0.47-0.72] for the TCA concentration. Very few studies evaluated the accuracy of QTc, T 40 ms axis and the R/S ratio. CONCLUSIONS Overall, the studies suggested that the ECG and TCA concentration have similar but relatively poor performance for predicting complications, such as seizures, VA or death, associated with TCA overdose.
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Affiliation(s)
- Benoit Bailey
- Division of Emergency Medicine and Clinical Pharmacology, Department of Pediatrics, Hôpital Ste-Justine, Université de Montréal, Montréal, Canada.
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Abstract
Moderate to severe pain frequently accompanies chronic diseases in general and end-stage renal disease (ESRD) in particular. Several analgesic agents and associated metabolites show altered pharmacokinetics in the presence of reduced glomerular filtration rate. Drug-related side effects may exacerbate symptoms frequently observed in persons with chronic kidney disease (CKD; eg, fatigue, nausea, vomiting, and constipation) or those often attributed to hemodialysis therapy (eg, orthostatic hypotension and impaired cognition). Persons with advanced CKD and ESRD are at increased risk for adverse effects of analgesic agents because of enhanced drug sensitivity, comorbid conditions, and concurrent medication use. Dose adjustment and avoidance of certain analgesics may be required in patients with advanced CKD and ESRD. We review the available evidence on pharmacokinetics and adverse drug effects of various analgesic agents commonly used in patients with advanced CKD and ESRD. Determining an optimal approach to the control of pain in patients with advanced CKD and ESRD will require additional research.
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Affiliation(s)
- Manjula Kurella
- Division of Nephrology, Moffitt-Long Hospital, University of California San Francisco, San Francisco, CA 94118-1211, USA
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43
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Harrigan RA, Pollack ML, Chan TC. Electrocardiographic manifestations: bundle branch blocks and fascicular blocks. J Emerg Med 2003; 25:67-77. [PMID: 12865112 DOI: 10.1016/s0736-4679(03)00129-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intraventricular conduction block is the general name given to a varied group of electrocardiographic entities. All share a common finding of some degree of delay in ventricular activation; recognition of these blocks hinges upon analysis of the QRS complex, as well as the ST-T changes associated with them. Bundle branch block (right or left), and fascicular block (left anterior or left posterior) are all examples of intraventricular conduction block. Causation of intraventricular conduction block may be cardiac or noncardiac; early recognition of the etiology may be of clinical importance. This article reviews the basic anatomy and physiology related to intraventricular conduction blocks, and then examines each in terms of electrocardiographic definition and clinical correlation.
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Affiliation(s)
- Richard A Harrigan
- Department of Emergency Medicine, Temple University Hospital, Jones Hall 10th Floor, Ontario Street & Park Avenue, Philadelphia, PA 19140, USA
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Sharma AN, Hexdall AH, Chang EK, Nelson LS, Hoffman RS. Diphenhydramine-induced wide complex dysrhythmia responds to treatment with sodium bicarbonate. Am J Emerg Med 2003; 21:212-5. [PMID: 12811715 DOI: 10.1016/s0735-6757(02)42248-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Diphenhydramine, a common ingredient in over-the-counter medications, is often taken in overdose. Toxicity is usually limited to anticholinergic symptoms. However, because diphenhydramine also exhibits type IA sodium channel blockade, cardiac toxicity is also possible. Although it would be expected that, like other type IA toxicities, diphenhydramine-induced cardiotoxicity could be responsive to hypertonic sodium bicarbonate, this finding is largely unappreciated. We describe 3 cases of diphenhydramine-induced cardiac toxicity that were responsive to bicarbonate.
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Affiliation(s)
- Adhi N Sharma
- New York City Poison Control Center, New York, NY, USA.
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Abstract
Many patients are believed to be at risk of dysrhythmias and are felt to require cardiac monitoring. These patients may not be deemed ill enough to occupy a high dependency or critical care bed and are monitored on general wards. Monitoring policies vary widely not only between institutions, but also between individual medical staff. These variations occur due to differing availability of resources and due to the lack of consensus regarding the risk for an individual patient. There is no clear evidence that monitoring patients outside high dependency areas is of benefit; inappropriate use of monitoring may actually increase patient risk.
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Buckley NA, Chevalier S, Leditschke IA, O'Connell DL, Leitch J, Pond SM. The limited utility of electrocardiography variables used to predict arrhythmia in psychotropic drug overdose. Crit Care 2003; 7:R101-7. [PMID: 12974977 PMCID: PMC270716 DOI: 10.1186/cc2345] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2003] [Revised: 06/06/2003] [Accepted: 06/11/2003] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of the present study was to examine the relationship between serious arrhythmias in patients with psychotropic drug overdose and electrocardiography (ECG) findings that have been suggested previously to predict this complication. METHODS Thirty-nine patients with serious arrhythmias (ventricular tachycardia, supraventricular tachycardia or cardiac arrest) after tricyclic antidepressant overdose or thioridazine overdose were compared with 117 controls with clinically significant overdose matched to each case for the drug ingested. These patients with psychotropic drug overdose had presented for treatment to the Department of Clinical Toxicology, Newcastle and to the Princess Alexandra Hospital, Brisbane. The heart rate, the QRS width, the QTc and QT intervals, the QT dispersion, and the R wave and R/S ratios in aVR on the initial ECGs were compared in cases and controls. RESULTS The cases had taken dothiepin (16 patients), doxepin (six patients), thioridazine (five patients), amitriptyline (five patients), nortriptyline (three patients), imipramine (one patient) and a combination of dothiepin and thioridazine (three patients). In 20 of the 39 patients with arrhythmias, the arrhythmia had been a presumed ventricular tachycardia. Of the other 19 patients, 15 patients had a supraventricular tachycardia, two patients had cardiac arrests (one asystole, one without ECG monitoring) and two patients had insufficient data recorded to make classification of the arrhythmias possible. The QRS was >/= 100 ms in 82% of cases but also in 76% of controls. QRS >/= 160 ms had a sensitivity of only 13% and occurred in 2% of controls. QRS > 120 ms, QTc > 500 and the R/S ratio in aVR appeared to have a stronger association with the occurrence of arrhythmia: QRS > 120 ms (odds ratio [OR], 3.56; 95% confidence interval [CI], 1.46-8.68), QTc > 500 (OR, 3.07; 95% CI, 1.33-7.07), and R/S ratio in aVR > 0.7 (OR, 16; 95% CI, 3.47-74). Excluding thioridazine overdoses and performing the analysis for tricyclic antidepressant overdoses alone gave increased odds ratios for QRS > 120 ms (OR, 4.83; 95% CI, 1.73-13.5) and QTc > 500 (OR, 4.5; 95% CI, 1.56-13) but had little effect on that for the R/S ratio in aVR > 0.7 (OR, 14.5; 95% CI, 3.10-68). CONCLUSION ECG measurements were generally weakly related to the occurrence of arrhythmia and should not be used as the sole criteria for risk assessment in tricyclic antidepressant overdose. The frequently recommended practice of using either QRS >/= 100 ms or QRS >/= 160 ms to predict arrhythmias is not supported by our study. R/S ratio in aVR > 0.7 was most strongly related to arrhythmia but had estimated positive and negative predictive values of only 41% and 95%, respectively. The use of these specific predictors in other drug overdoses is not recommended without specific studies.
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Singh N, Singh HK, Khan IA. Serial electrocardiographic changes as a predictor of cardiovascular toxicity in acute tricyclic antidepressant overdose. Am J Ther 2002; 9:75-9. [PMID: 11782822 DOI: 10.1097/00045391-200201000-00012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Tricyclic antidepressant agents continue to be a leading cause of significant morbidity and mortality in reported poisonings involving pharmaceutical agents. Although the history and physical examination play an important role in the assessment of patients with tricyclic antidepressant overdose, the presence of anticholinergic features on examination cannot predict the severity of the overdose. Several clinical variables, in particular electrocardiographic (ECG) changes, have been proposed as a guide to determine the severity of the tricyclic antidepressant poisoning. The authors describe a patient with tricyclic antidepressant overdose who presented with altered mental status and whose serial ECG changes played a significant role in diagnosing and predicting the impending cardiovascular toxicity. The role of ECG changes in making the diagnosis and assessing the severity of the tricyclic antidepressant overdose is reviewed.
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Affiliation(s)
- Narpinder Singh
- Department of Internal Medicine, Long Island College Hospital, Brooklyn, NY, USA
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49
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Affiliation(s)
- N J Mehta
- Department of Internal Medicine, Long Island College Hospital, Brooklyn, New York, USA
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50
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Abstract
The tricyclic antidepressant (TCA) agents are recognized for their potentially lethal cardiovascular and neurological effects in poisoned patients. The 12-lead electrocardiogram (ECG) has emerged as a popular bedside tool in the evaluation of TCA toxicity. Although the history and physical examination play a key role in the assessment of the patient with potential TCA poisoning, the presence or absence of features of the TCA toxidrome are not sufficient to detect or exclude toxicity from this class of drugs. A variety of ECG findings occur with TCA toxicity. Aside from the sinus tachycardia due principally to anticholinergic effects, TCA-toxic changes seen on the ECG are attributable primarily to the sodium channel blockade caused by these agents. The majority of patients at significant risk for developing cardiac or neurological toxicity will have a QRS complex greater than 0.10 seconds or a rightward shift of the terminal 40 ms of the frontal plane QRS complex vector. The majority of these patients will also display these changes early in their emergency department stay. However, the appearance of these findings, either alone or in combination, does not mean the patient will develop significant cardiac or neurological toxicity. The ECG can neither unequivocally rule in nor rule out impending toxicity; recognizing these limitations, the emergency physician can use this bedside tool in combination with other clinical data during the assessment of the poisoned patient.
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Affiliation(s)
- R A Harrigan
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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