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Antidepressant Poisoning Trends in Pediatric Intensive Care: A Comparative Study of New- and Old-Generation Antidepressants. J Clin Psychopharmacol 2023; 43:139-144. [PMID: 36795032 DOI: 10.1097/jcp.0000000000001668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE/BACKGROUND This study aimed to compare the frequency, clinical findings, treatment practices, and outcomes of toxicity to old-generation (OG) and new-generation (NG) antidepressants in our pediatric intensive care unit (PICU) by year-to-year. METHODS/PROCEDURES The study included patients hospitalized for antidepressant poisoning during the 11-year period of January 2010 through December 2020. Antidepressants were classified as OG and NG. The groups were compared in terms of patient demographic characteristics, type of poisoning (accidental/suicidal), clinical findings, supportive and extracorporeal treatments received, and outcomes. FINDINGS/RESULTS The study included 58 patients (NG, n = 30; OG, n = 28). The median age of the patients was 178 months (range, 13.6-215 months) and 47 patients (81%) were female. Patients admitted for only antidepressant poisoning constituted 13.3% of all poisoning cases (58/436). Of these, 22 cases (37.9%) were accidental and 36 (62.3%) were suicidal. The most common cause of poisoning was amitriptyline (24/28) in the OG group and sertraline (13/30) in the NG group. Neurological symptoms were significantly more common in the OG group (76.2% vs 23.8%), while gastrointestinal involvement was more common in the NG group (82% vs 18%; P = 0.001 and P = 0.026, respectively). Old-generation antidepressant poisoning was associated with more frequent intubation (4 vs 0 patients, P = 0.048) and longer length of PICU stay (median, 1 day [range, 1-8] vs 1 day [range, 1-4], P = 0.019). Rates of therapeutic plasma exchange and intravenous lipid emulsion therapy did not differ ( P = 0.483 and P = 0.229, respectively). IMPLICATIONS/CONCLUSIONS In poisoned patients, proper evaluation and management of patients requiring PICU admission are vital for favorable patient outcomes.
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Nagano A, Muto M, Shida J, Kazama I. Amitriptyline intoxication in bullfrogs causes widening of QRS complexes in electrocardiogram. J Vet Med Sci 2023; 85:175-179. [PMID: 36596558 PMCID: PMC10017290 DOI: 10.1292/jvms.22-0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Amitriptyline intoxication is caused by its suicidal or accidental overdose. In the present study, by intravenously injecting 1.5 or 3.0 mg/kg amitriptyline into bullfrogs, we actually revealed that amitriptyline causes the widening of QRS complexes in electrocardiogram (ECG). In simultaneous recordings of the cardiac action potential, amitriptyline decreased the slope of phase 0 in the action potential, indicating the inhibition of the inward sodium currents during this phase. The following treatment with sodium bicarbonate quickly restored the widened QRS complexes in the ECG, demonstrating the counteraction with the sodium channel blockade caused by amitriptyline. The dual recordings of ECG waveforms and the action potential in cardiomyocytes enabled us to demonstrate the mechanisms of characteristic ECG abnormalities caused by amitriptyline intoxication.
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Affiliation(s)
- Amu Nagano
- School of Nursing, Miyagi University, Miyagi, Japan
| | - Mizuki Muto
- School of Nursing, Miyagi University, Miyagi, Japan
| | - Junko Shida
- Department of Life Sciences, Yamagata University, Yamagata, Japan
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Kamasak T, Kader Ş, Mutlu M, Özkaya K, Erduran E, Orhan F, Dilber E, Kalyoncu M, Karagüzel G, Cakır M, Bahat E, Cansu A. Amitriptyline Intoxication in Children: Twenty Years' Experience in a Tertiary Care Center in Turkey. Pediatr Emerg Care 2021; 37:e1377-e1381. [PMID: 32150000 DOI: 10.1097/pec.0000000000002055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Amitriptyline ingestion is an important cause of poisoning morbidity and mortality in Turkey and other countries. In contrast to adults, data concerning amitriptyline intoxication in children are limited. The purpose of this study was to investigate amitriptyline intoxication findings in the pediatric population, based on age groups and reported dosages. METHODS The medical records of 192 patients admitted to the Karadeniz Technical University Medical Faculty Farabi Hospital Pediatric Emergency Department, Turkey, due to amitriptyline intoxication in 1997-2017 were examined retrospectively. Patients were divided into 6 groups based on amitriptyline doses and 4 groups based on age. Complete blood count, blood glucose, serum electrolytes, renal and liver function tests, coagulation tests (prothrombin time and partial thromboplastin time), and blood gas analysis were studied in all patients. Electrocardiography was performed on all children, and chest radiography and electroencephalography on those with respiratory or central nervous system symptoms. RESULTS Amitriptyline intoxication was most frequently observed between the ages of 1 and 4 years. The most common signs and symptoms observed at time of hospital admission were lethargy and drowsiness (45.3%), sinus tachycardia (19.2%), and nausea and vomiting (13%). The most common laboratory finding was hyperglycemia (17.7). Six patients were intubated because of respiratory failure, and mechanical ventilation was initiated in these cases. One patient with amitriptyline overdose had persistent supraventricular tachycardia. Four children died due to amitriptyline intoxication. CONCLUSIONS Tricyclic antidepressant intoxication is a leading cause of mortality and morbidity in children. It is therefore particularly important to identify the clinical and laboratory findings that develop with high-dose consumption.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Elif Bahat
- Pediatric Nephrology, Karadeniz Technical University, Trabzon, Turkey
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Neumann J, Binter MB, Fehse C, Marušáková M, Büxel ML, Kirchhefer U, Hofmann B, Gergs U. Amitriptyline functionally antagonizes cardiac H 2 histamine receptors in transgenic mice and human atria. Naunyn Schmiedebergs Arch Pharmacol 2021; 394:1251-1262. [PMID: 33625558 PMCID: PMC8208937 DOI: 10.1007/s00210-021-02065-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/09/2021] [Indexed: 11/29/2022]
Abstract
We have previously shown that histamine (2-(1H-imidazol-4-yl)ethanamine) exerted concentration-dependent positive inotropic effects (PIE) or positive chronotropic effects (PCE) on isolated left and right atria, respectively, of transgenic (H2R-TG) mice that overexpress the human H2 histamine receptor (H2R) in the heart; however, the effects were not seen in their wild-type (WT) littermates. Amitriptyline, which is still a highly prescribed antidepressant drug, was reported to act as antagonist on H2Rs. Here, we wanted to determine whether the histamine effects in H2R-TG were antagonized by amitriptyline. Contractile studies were performed on isolated left and right atrial preparations, isolated perfused hearts from H2R-TG and WT mice and human atrial preparations. Amitriptyline shifted the concentration-dependent PIE of histamine (1 nM-10 μM) to higher concentrations (rightward shift) in left atrial preparations from H2R-TG. Similarly, in isolated perfused hearts from H2R-TG and WT mice, histamine increased the contractile parameters and the phosphorylation state of phospholamban (PLB) at serine 16 in the H2R-TG mice, but not in the WT mice. However, the increases in contractility and PLB phosphorylation were attenuated by the addition of amitriptyline in perfused hearts from H2R-TG. In isolated electrically stimulated human atria, the PIE of histamine that was applied in increasing concentrations from 1 nM to 10 μM was reduced by 10-μM amitriptyline. In summary, we present functional evidence that amitriptyline also acts as an antagonist of contractility at H2Rs in H2R-TG mouse hearts and in the human heart which might in part explain the side effects of amitriptyline.
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Affiliation(s)
- Joachim Neumann
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Maximilian Benedikt Binter
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Charlotte Fehse
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Margaréta Marušáková
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
| | - Maren Luise Büxel
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Uwe Kirchhefer
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Westfälische Wilhelms-Universität, Domagkstr. 12, D-48149, Münster, Germany
| | - Britt Hofmann
- Cardiac Surgery, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06120, Halle, Germany
| | - Ulrich Gergs
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany.
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Abstract
Pharmaceutical ingestions comprise an important part of pediatric toxicology. Based on the 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System, coupled with recent epidemiology articles on the topic of pediatric toxicology, it is apparent that poison prevention education has not been completely successful in decreasing exposures to toxic drugs. From the unintentional ingestion in a toddler due to unsafe storage to the intentional adolescent ingestion for misuse and abuse, pharmaceutical medications continue to cause harm. Access to adult prescription drugs in the home accounted for most of the exposures in children age ≤5 years as well as adolescents age 13 to 19 years. Ingestions resulting from more common pharmaceutical exposures are discussed with the hope of increasing awareness about the need for added vigilance. [Pediatr Ann. 2017;46(12):e459-e465.].
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Prolonged Antimuscarinic Delirium in a Child Due to Benztropine Exposure Treated With Multiple Doses of Physostigmine. Pediatr Emerg Care 2016; 32:243-5. [PMID: 26383155 DOI: 10.1097/pec.0000000000000503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An 11-year-old boy presented with an antimuscarinic toxidrome due to benztropine and risperidone ingestion. His delirium was prolonged and difficult to treat with benzodiazepines. Multiple doses of physostigmine successfully treated it. Benztropine is a potent antimuscarinic agent, whereas risperidone has not been reported to cause antimuscarinic toxicity. The use of physostigmine to treat benztropine intoxication in a pediatric patient has not previously been described. In this case, multiple doses were used and were well tolerated.
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Paksu MS, Zengin H, Ilkaya F, Paksu S, Guzel H, Ucar D, Uzun A, Alacam H, Duran L, Murat N, Guzel A. Can empirical hypertonic saline or sodium bicarbonate treatment prevent the development of cardiotoxicity during serious amitriptyline poisoning? Experimental research. Cardiovasc J Afr 2015; 26:134-9. [PMID: 25939777 PMCID: PMC4538909 DOI: 10.5830/cvja-2015-014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/27/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aim of this experimental study was to investigate whether hypertonic saline or sodium bicarbonate administration prevented the development of cardiotoxicity in rats that received toxic doses of amitriptyline. METHOD Thirty-six Sprague Dawley rats were used in the study. The animals were divided into six groups. Group 1 received toxic doses of i.p. amitriptyline. Groups 2 and 3 toxic doses of i.p. amitriptyline, plus i.v. sodium bicarbonate and i.v. hypertonic saline, respectively. Group 4 received only i.v. sodium bicarbonate, group 5 received only i.v. hypertonic saline, and group 6 was the control. Electrocardiography was recorded in all rats for a maximum of 60 minutes. Blood samples were obtained to measure the serum levels of sodium and ionised calcium. RESULTS The survival time was shorter in group 1. In this group, the animals' heart rates also decreased over time, and their QRS and QTc intervals were significantly prolonged. Groups 2 and 3 showed less severe changes in their ECGs and the rats survived for a longer period. The effects of sodium bicarbonate or hypertonic saline treatments on reducing the development of cardiotoxicity were similar. The serum sodium levels decreased in all the amitriptyline-applied groups. Reduction of serum sodium level was most pronounced in group 1. CONCLUSION Empirical treatment with sodium bicarbonate or hypertonic saline can reduce the development of cardiotoxicity during amitriptyline intoxication. As hypertonic saline has no adverse effects on drug elimination, it should be considered as an alternative to sodium bicarbonate therapy.
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Affiliation(s)
- Muhammet Sukru Paksu
- Paediatric Intensive Care Unit, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Halit Zengin
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
| | - Fatih Ilkaya
- Department of Pharmacology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sule Paksu
- Department of Paediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hasan Guzel
- Department of Pharmacology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Durmus Ucar
- Department of Physiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Adem Uzun
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hasan Alacam
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Latif Duran
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Naci Murat
- Department of Industrial Engineering, Faculty of Engineering, Ondokuz Mayis University, Samsun, Turkey
| | - Ahmet Guzel
- Department of Paediatric Emergency, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Allibe N, Eysseric-Guerin H, Kintz P, Bartoli M, Bost-Bru C, Grenier F, Scolan V, Stanke-Labesque F. Amitriptyline poisoning of a baby: How informative can hair analysis be? Forensic Sci Int 2015; 249:53-8. [DOI: 10.1016/j.forsciint.2015.01.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 01/13/2015] [Accepted: 01/21/2015] [Indexed: 11/28/2022]
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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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Turkmen Z, Mercan S, Bavunoglu I, Cengiz S. Development and validation of a densitometric-high-performance thin-layer chromatographic method for quantitative analysis of amitriptyline in gastric lavage. JPC-J PLANAR CHROMAT 2013. [DOI: 10.1556/jpc.26.2013.6.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
A 1-year-old boy presented to the emergency department with drowsiness after intoxication from amitriptyline cream. The amitriptyline level in his blood was in the high-therapeutic range for adults. He was admitted for cardiac monitoring. Except for a short episode with irregular heart rate, he recovered completely within 24 hours without adjuvant treatment. Amitriptyline is known as an antidepressant but is also prescribed for neuropathic pain. It is usually prescribed in tablet form; the cream is a novel application. In children, intoxication with amitriptyline may cause drowsiness, seizures, coma, hypotension, tachycardia, and life-threatening cardiac arrhythmias. This is the first case report presenting intoxication in a child with amitriptyline cream. It stresses the importance of keeping children away from the medicine cabinet, even from creams or ointments.
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Affiliation(s)
- Nathalie S M Lak
- Meander Medical Centre, Ringweg Randenbroek 110, 3816 CP Amersfoort, the Netherlands
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Clement A, Raney JJ, Wasserman GS, Lowry JA. Chronic amitriptyline overdose in a child. Clin Toxicol (Phila) 2012; 50:431-4. [PMID: 22462596 DOI: 10.3109/15563650.2012.672987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Amitriptyline, a tricyclic antidepressant, has a well-described toxicity profile, and acute ingestions are common in the pediatric toxicology world. However, little can be found in the literature regarding chronic overdose. We describe a case of a 6-year-old girl who was prescribed amitriptyline 30 mg nightly for sleep problems, but was mistakenly given 300 mg (15 mg/kg) nightly for over a month. She was noted to have mental status changes and difficulty reading several days after starting the medication. She presented to the local children's hospital in status epilepticus with significant cardiac conduction abnormalities on ECG. Her total amitriptyline/nortriptyline level was found to be 1676 ng/mL (normal therapeutic level 50-300 ng/mL). She was treated for several days with sodium bicarbonate. Within 24 h, her neurologic status improved and had returned to baseline within several days. Her ECG normalized, and she was discharged home, without apparent sequelae. A brief discussion of possible protective mechanisms (including pharmacogenomic) is presented.
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Affiliation(s)
- Alan Clement
- Department of Graduate Medical Education, Division of Clinical Pharmacology and Medical Toxicology, University of Missouri School of Medicine, Kansas City, MO, USA
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Temporary cardiac pacemaker in the treatment of junctional rhythm and hypotension due to imipramine intoxication. Pediatr Cardiol 2011; 32:521-4. [PMID: 21336976 DOI: 10.1007/s00246-011-9914-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 01/31/2011] [Indexed: 10/18/2022]
Abstract
Tricyclic antidepressants (TCAs) account for approximately 3% of all pediatric hospitalizations due to poisoning. TCAs remain a common cause of fatal drug poisoning because of their cardiovascular toxicity as manifested by electrocardiogram (ECG) abnormalities, arrhythmias, and hypotension. We report a 15-year-old girl with junctional escape rhythm and resistant hypotension caused by severe imipramine intoxication. Initial ECG showed junctional escape rhythm (46 bpm) with no atrial activity, low QRS voltage, widening of the QRS complex (160 ms) with a right bundle branch-like pattern, R wave > 3 mm in aVR (6 mm), and prolongation of the QT interval (QTc 550 ms). Despite intravenous fluids and inotropic support, she had resistant hypotension and acute renal failure. Junctional rhythm was successfully terminated by using temporary cardiac pacemaker. Hemodialysis and hemoperfusion were also performed. She was discharged on the day 5 without any complications. During follow-up, no ECG abnormalities were noted. We reported successful use of temporary cardiac pacemaker for treatment of junctional rhythm and resistant hypotension in imipramine intoxication. The conventional methods of activated charcoal, alkalinization, and symptomatic treatment of complications are usually enough for nonlethal doses of TCA intoxication. However, in imipramine intoxication with serious arrythmias and hypotension, using temporary cardiac pacemaker, hemodialysis, and hemoperfusion can be a life-saving therapeutic approach.
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Fanton J, Gleason MM. Psychopharmacology and preschoolers: a critical review of current conditions. Child Adolesc Psychiatr Clin N Am 2009; 18:753-71. [PMID: 19486849 DOI: 10.1016/j.chc.2009.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Rates of prescriptions for very young children have increased notably in the last 20 years. These changes have occurred in the context of increasing attention to early childhood mental health, availability of medications perceived to be safer than older medications, application of the medical model to the mental health care of young children, as well as other cultural shifts. Psychopharmacological treatment for any patient, but especially very young children, requires consideration of central nervous system (CNS) and metabolic development and issues of diagnostic validity and should be guided by an empirical literature. In young children, this literature is quite limited. In this article, the authors review developmental issues involved in psychopharmacological treatment and present existing literature and practical guidelines for common preschool diagnoses, recognizing that for some disorders, the extant literature does not support even consideration of medications.
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Affiliation(s)
- John Fanton
- Department of Psychiatry, Tufts University School of Medicine, Western Campus at Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA.
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Belen B, Akman A, Yüksel N, Dilsiz G, Yenicesu I, Olguntürk R. A Case Report of Amitriptyline Poisoning Successfully Treated With the Application of Plasma Exchange. Ther Apher Dial 2009; 13:147-9. [DOI: 10.1111/j.1744-9987.2009.00669.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Amitriptyline is one of the major tricyclic antidepressants, and the data on amitriptyline poisoning in children are limited. OBJECTIVES To present our experiences with amitriptyline poisoning in children, particularly with regard to its effects on electrocardiogram (ECG) and relation with clinical status. METHODS Clinical, laboratory, and electrocardiographic findings in 52 children admitted with amitriptyline poisoning were reviewed. Patients were divided into 2 groups according to age, as 6 years or younger (group A) and older than 6 years (group B). RESULTS Mean age was 4.6 +/- 3.0 years. Thirty-one patients were male, and 41 were 6 years or younger. Ingested amitriptyline dose was known in 23 patients (range, 2.3 mg/kg-27 mg/kg). The most frequent findings were lethargy (76.9%), sinus tachycardia (57.7%), and coma (48.1%). Four patients had a history of convulsion. The most common laboratory abnormalities were hyponatremia (26.9%) and leukocytosis (25%). Elevated transaminase levels were observed in 4 patients. In ECG, 11 (22.4%) patients had QTc prolongation and in 4 (8.2%) of them, it was significant. In 4 patients (8.2%), the QRS duration was 100 ms or longer and in 15 patients, the R wave in aVR was 3 mm or longer. The frequencies of clinical, laboratory, and electrocardiographic findings were similar between the 2 age groups (P > 0.05). No clinically apparent arrhythmias were observed. The positive predictive value of a widened QRS was 100% in terms of coma. None of the patients with an R wave in aVR of less than 3 mm developed convulsion; thus, the negative predictive value of an R wave in aVR of 3 mm or longer was 100% in terms of convulsion. CONCLUSIONS Amitriptyline poisoning may result in severe toxicity. Frequencies of clinical, laboratory, and ECG findings were similar in the 2 age groups. Amitriptyline overdose results in some ECG changes that can possibly help to predict the results of poisoning. Absence of an R wave in aVR of 3 mm or longer predicts seizures with a high negative predictive value, and a QRS duration of 100 or longer ms predicts coma with a high positive predictive value.
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Affiliation(s)
- Marinella Astuto
- Department of Anaesthesia and Intensive Care, Catania University Hospital, Catania, Italy
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