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Pai K, Buckley NA, Isoardi KZ, Isbister GK, Becker T, Chiew AL, Cairns R, Brown JA, Chan BS. Optimising alkalinisation and its effect on QRS narrowing in tricyclic antidepressant poisoning. Br J Clin Pharmacol 2021; 88:723-733. [PMID: 34312917 DOI: 10.1111/bcp.15008] [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: 03/25/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS The objectives were to determine the effect of NaHCO3 and/or mechanical ventilation on the biochemical profile and serum alkalinisation in tricyclic antidepressant (TCA) poisoning and investigate the impact of effective alkalinisation therapy on the QRS interval in TCA poisoning. METHODS This was a retrospective review of TCA poisonings from three Australian toxicology units and a poisons information centre (Jan 2013 to Jan 2019). We included patients with TCA toxicity who ingested>10 mg/kg or had clinically significant toxicities consistent with TCA poisoning, and analysed patients' clinical, electrocardiogram and biochemical data. RESULTS Of 210 patients, 84 received NaHCO3 and ventilation (dual therapy), 12 NaHCO3 , 46 ventilation and 68 supportive care treatment. When compared with single/supportive groups, patients who received dual therapy had taken a significantly higher median dose of TCA (1.5 g vs1.3 g, P < .001), a longer median maximum QRS interval (124 ms, interquartile ranges [IQR] 108-138 vs106 ms, IQR 98-115, P < .001) and were more likely to have seizures (14% vs3%, P = .006) and arrhythmias (17% vs1%, P < .001). The dual therapy group demonstrated greater increases in serum pH (median 0.11, IQR 0.04-0.17) compared to the single/supportive therapy group (median 0.03, IQR -0.01-0.09, p < .001). A greater proportion of patients reached the target pH 7.45-7.55 in the dual therapy group (59%) compared to the single/supportive therapy group (10%) (P < .001). For each 100 mmol bolus of NaHCO3 given, the median increase in serum sodium was 2.5 mmol/L (IQR 1.5-4.0). QRS narrowing occurred twice as quickly in the dual therapy vs single/supportive therapy group. CONCLUSIONS A combination of NaHCO3 and mechanical ventilation was most effective in achieving serum alkalinisation and was associated with a more rapid narrowing of the QRS interval. We advise that the maximal dose of NaHCO3 should be <400 mmol (6 mmol/kg).
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Affiliation(s)
- Kieran Pai
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Mater Department of Clinical Toxicology and Pharmacology, Calvary Mater Hospital, Waratah, New South Wales, Australia
| | - Therese Becker
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Angela L Chiew
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Rose Cairns
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jared A Brown
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Betty S Chan
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Abstract
Amitriptyline was the second tricyclic antidepressant to appear on the market for major depressive disorder under the brand name Elavil in 1961. Since its emergence, amitriptyline has been an effective therapeutic in various disease states and disorders but has also been a concerning source of cardiotoxicity. Amitriptyline inhibits serotonin and norepinephrine reuptake as well as produces off-target activity at histaminergic, muscarinic, and various other receptors. Its role as a modulator of monoamines helped further establish the monoamine theory to understand various mood disorders, paving the way for the now more common selective serotonin/norepinephrine reuptake inhibitors. In this review, we will discuss amitriptyline's synthesis, manufacturing information, drug metabolism, pharmacology, adverse effects, and its history and importance in therapy to present amitriptyline as a true classic in chemical neuroscience.
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Affiliation(s)
- Elliot W. McClure
- Department of Pharmaceutical Sciences, Lipscomb University College of Pharmacy and Health Sciences, Nashville, Tennessee 37204, United States
| | - R. Nathan Daniels
- Department of Pharmaceutical Sciences, Lipscomb University College of Pharmacy and Health Sciences, Nashville, Tennessee 37204, United States
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232-6600, United States
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Dodd S, Mitchell PB, Bauer M, Yatham L, Young AH, Kennedy SH, Williams L, Suppes T, Lopez Jaramillo C, Trivedi MH, Fava M, Rush AJ, McIntyre RS, Thase ME, Lam RW, Severus E, Kasper S, Berk M. Monitoring for antidepressant-associated adverse events in the treatment of patients with major depressive disorder: An international consensus statement. World J Biol Psychiatry 2018; 19:330-348. [PMID: 28984491 DOI: 10.1080/15622975.2017.1379609] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES These recommendations were designed to ensure safety for patients with major depressive disorder (MDD) and to aid monitoring and management of adverse effects during treatment with approved antidepressant medications. The recommendations aim to inform prescribers about both the risks associated with these treatments and approaches for mitigating such risks. METHODS Expert contributors were sought internationally by contacting representatives of key stakeholder professional societies in the treatment of MDD (ASBDD, CANMAT, WFSBP and ISAD). The manuscript was drafted through iterative editing to ensure consensus. RESULTS Adequate risk assessment prior to commencing pharmacotherapy, and safety monitoring during pharmacotherapy are essential to mitigate adverse events, optimise the benefits of treatment, and detect and assess adverse events when they occur. Risk factors for pharmacotherapy vary with individual patient characteristics and medication regimens. Risk factors for each patient need to be carefully assessed prior to initiating pharmacotherapy, and appropriate individualised treatment choices need to be selected. Some antidepressants are associated with specific safety concerns which were addressed. CONCLUSIONS Risks of adverse outcomes with antidepressant treatment can be managed through appropriate assessment and monitoring to improve the risk benefit ratio and improve clinical outcomes.
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Affiliation(s)
- Seetal Dodd
- a School of Medicine, Barwon Health , Deakin University, IMPACT SRC (Innovation in Mental and Physical Health and Clinical Treatment - Strategic Research Centre) , Geelong , Australia.,b Department of Psychiatry , University of Melbourne , Melbourne , Australia.,c Mental Health Drug and Alcohol Services , University Hospital Geelong, Barwon Health , Geelong , Australia.,d Orygen The National Centre of Excellence in Youth Mental Health , Parkville , Australia
| | - Philip B Mitchell
- f School of Psychiatry , University of New South Wales, and Black Dog Institute , Sydney , Australia
| | - Michael Bauer
- g Department of Psychiatry and Psychotherapy , University Hospital Carl Gustav Carus, Technische, Universität Dresden , Dresden , Germany
| | - Lakshmi Yatham
- h Department of Psychiatry , University of British Columbia , British Columbia , BC , Canada
| | - Allan H Young
- i Department of Psychological Medicine , Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK & South London and Maudsley NHS Foundation Trust , London , UK
| | - Sidney H Kennedy
- j Department of Psychiatry , University of Toronto , Toronto , ON , Canada
| | - Lana Williams
- a School of Medicine, Barwon Health , Deakin University, IMPACT SRC (Innovation in Mental and Physical Health and Clinical Treatment - Strategic Research Centre) , Geelong , Australia
| | - Trisha Suppes
- k Department of Psychiatry & Behavioral Sciences , School of Medicine, Stanford University , Stanford , CA , USA
| | | | - Madhukar H Trivedi
- m Department of Psychiatry , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Maurizio Fava
- n Division of Clinical Research , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA
| | - A John Rush
- o Duke-National University of Singapore Medical School , Singapore , Singapore
| | - Roger S McIntyre
- j Department of Psychiatry , University of Toronto , Toronto , ON , Canada.,p Mood Disorders Psychopharmacology Unit, University of Toronto , Toronto , ON , Canada.,q Brain and Cognition Discovery Foundation , Toronto , ON , Canada
| | - Michael E Thase
- r Department of Psychiatry, Perelman School of Medicine , University of Pennsylvania , Pennsylvania , PA , USA
| | - Raymond W Lam
- h Department of Psychiatry , University of British Columbia , British Columbia , BC , Canada
| | - Emanuel Severus
- g Department of Psychiatry and Psychotherapy , University Hospital Carl Gustav Carus, Technische, Universität Dresden , Dresden , Germany
| | - Siegfried Kasper
- s Department of Psychiatry and Psychotherapy , Medical University of Vienna , Wien , Austria
| | - Michael Berk
- a School of Medicine, Barwon Health , Deakin University, IMPACT SRC (Innovation in Mental and Physical Health and Clinical Treatment - Strategic Research Centre) , Geelong , Australia.,b Department of Psychiatry , University of Melbourne , Melbourne , Australia.,c Mental Health Drug and Alcohol Services , University Hospital Geelong, Barwon Health , Geelong , Australia.,d Orygen The National Centre of Excellence in Youth Mental Health , Parkville , Australia.,e The Florey Institute of Neuroscience and Mental Health , Parkville , Australia
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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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Randhawa K, Kumar D, Jamwal A, Kumar S. Screening of antidepressant activity and estimation of quercetin from Coccinia indica using TLC densitometry. PHARMACEUTICAL BIOLOGY 2015; 53:1867-1874. [PMID: 25845639 DOI: 10.3109/13880209.2015.1025289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
CONTEXT Coccinia indica Naud (Cucurbitaceae) has been traditionally used for the treatment of depression but these claims have not been validated. OBJECTIVES The objective of this study is to investigate antidepressant activity of various extracts and fractions of C. indica aerial parts, and to estimate content of quercetin in the plant using TLC densitometry. MATERIALS AND METHODS Coccinia indica aerial parts were successively extracted using solvents in increasing order of polarity, namely n-hexane, chloroform, methanol, and water. Various extracts were evaluated for antidepressant activity at doses of 200 or 400 mg/kg, p.o., upon acute administration in mice using the forced swim test (FST). The bioactive extract was partitioned successively using solvents in increasing order of polarity, namely n-hexane, ethyl acetate, and n-butanol. All fractions were also screened for antidepressant activity at doses of 25 or 50 mg/kg, p.o., upon acute administration in mice. RESULTS The methanol extract significantly reduced the duration of immobility in FST at dose of 400 mg/kg without affecting locomotor activity in open field test, thus, confirmed its antidepressant activity, which was statistically equivalent to the standard drug (imipramine, 15 mg/kg, i.p.). Ethyl acetate fraction (EAF) exhibited antidepressant activity at 50 mg/kg. Comparative TLC fingerprint studies confirmed the presence of quercetin in methanol extract and EAF. Quercetin was used as a chemical marker to standardize C. indica aerial parts using the validated TLC densitometric method, and the content of quercetin was found to be 0.00172% w/w. CONCLUSIONS The present studies scientifically validated traditional claims of C. indica for antidepressant activity.
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Affiliation(s)
- Kudrat Randhawa
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University , Patiala, Punjab , India
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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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Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: Pediatric Advanced Life Support. Circulation 2010; 122:S876-908. [DOI: 10.1161/circulationaha.110.971101] [Citation(s) in RCA: 473] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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9
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Mendoza-Sotelo J, Torner C, Alvarado-Vásquez N, Lazo-Langner A, López G, Arango I, Pavón L, González-Trujano E, Moreno J. Ultrastructural changes and immunolocalization of P-selectin in platelets from patients with major depression. Psychiatry Res 2010; 176:179-82. [PMID: 20193966 DOI: 10.1016/j.psychres.2009.07.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 06/18/2009] [Accepted: 07/30/2009] [Indexed: 11/25/2022]
Abstract
Depression is considered an important risk factor in patients with cardiovascular disease (CVD). Although the biological mechanism is unknown, it has been suggested that hyperactivity of platelets may have an important role in the onset and evolution of cardiovascular damage. The goals of this study were to evaluate by transmission electron microscopy and immunohistochemistry the presence of ultra-structural variations in platelets from individuals with recent diagnosis of major depression disease (MDD, patients without previous anti-depressant treatment and from healthy control subjects.). Platelets from depressed patients had a greater proportion of dendritic forms compared with those obtained from control subjects. Morphological changes, such as dilation of open canalicular and dense tubular systems, platelet vacuolization, electrodense pattern of membranes, and a different immunolocalization of P-selectin were observed in the platelets from depressed patients compared with those isolated from healthy subjects. Our results revealed ultra-structural changes in platelets isolated from patients with MDD suggestive of enhanced platelet activation.
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Bayrakci B, Unal S, Erkocoglu M, Güngör HY, Aksu S. Case Reports of Successful Therapeutic Plasma Exchange in Severe Amitriptyline Poisoning. Ther Apher Dial 2007; 11:452-4. [DOI: 10.1111/j.1744-9987.2007.00527.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support. Pediatrics 2006; 117:e1005-28. [PMID: 16651281 DOI: 10.1542/peds.2006-0346] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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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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Bradberry SM, Thanacoody HKR, Watt BE, Thomas SHL, Vale JA. Management of the Cardiovascular Complications of Tricyclic Antidepressant Poisoning. ACTA ACUST UNITED AC 2005; 24:195-204. [PMID: 16390221 DOI: 10.2165/00139709-200524030-00012] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Experimental studies suggest that both alkalinisation and sodium loading are effective in reducing cardiotoxicity independently. Species and experimental differences may explain why sodium bicarbonate appears to work by sodium loading in some studies and by a pH change in others. In the only case series, the administration of intravenous sodium bicarbonate to achieve a systemic pH of 7.5-7.55 reduced QRS prolongation, reversed hypotension (although colloid was also given) and improved mental status in patients with moderate to severe tricyclic antidepressant poisoning. This clinical study supports the use of sodium bicarbonate in the management of the cardiovascular complications of tricyclic antidepressant poisoning. However, the clinical indications and dosing recommendations remain to be clarified. Hypotension should be managed initially by administration of colloid or crystalloid solutions, guided by central venous pressure monitoring. Based on experimental and clinical studies, sodium bicarbonate should then be administered. If hypotension persists despite adequate filling pressure and sodium bicarbonate administration, inotropic support should be initiated. In a non-randomised controlled trial in rats, epinephrine resulted in a higher survival rate and was superior to norepinephrine both when the drugs were used alone or when epinephrine was used in combination with sodium bicarbonate. Sodium bicarbonate alone resulted in a modest increase in survival rate but this increased markedly when sodium bicarbonate was used with epinephrine or norepinephrine. Clinical studies suggest benefit from norepinephrine and dopamine; in an uncontrolled study the former appeared more effective. Glucagon has also been of benefit. Experimental studies suggest extracorporeal circulation membrane oxygenation is also of potential value. The immediate treatment of arrhythmias involves correcting hypoxia, electrolyte abnormalities, hypotension and acidosis. Administration of sodium bicarbonate may resolve arrhythmias even in the absence of acidosis and, only if this therapy fails, should conventional antiarrhythmic drugs be used. The class 1b agent phenytoin may reverse conduction defects and may be used for resistant ventricular tachycardia. There is also limited evidence for benefit from magnesium infusion. However, class 1a and 1c antiarrhythmic drugs should be avoided since they worsen sodium channel blockade, further slow conduction velocity and depress contractility. Class II agents (beta-blockers) may also precipitate hypotension and cardiac arrest.
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Affiliation(s)
- Sally M Bradberry
- National Poisons Information Service (Birmingham Centre), City Hospital, Birmingham, UK
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Adams BK, Mann MD, Aboo A, Isaacs S, Evans A. Prolonged gastric emptying half-time and gastric hypomotility after drug overdose. Am J Emerg Med 2004; 22:548-54. [PMID: 15666259 DOI: 10.1016/j.ajem.2004.08.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A prospective study was undertaken to determine if gastric motility and emptying are altered by the ingestion of overdoses of tricyclic antidepressants, acetaminophen, opioid-acetaminophen mixtures, carbamazepine or phenytoin. Gastric scintigraphy was used to measure gastric emptying half-time and assess gastric motility in 104 patients at initial presentation and again at follow-up (n = 85). Patients were imaged for 5 hours after being given 20 MBq of 99mTc tin colloid to drink. Drug serum levels were measured on all patients at initial presentation and at follow-up. We observed markedly prolonged gastric emptying half-times and severe hypomotility at initial presentation compared with follow-up in the vast majority of patients, except for a small group of patients with phenytoin poisoning. Twelve patients had gastric emptying half-times of over 300 minutes, a further 14 had half-times of over 200 minutes and 21 others had half-times of over 120 minutes. Poisoning is associated with hypomotility and a marked delay in gastric emptying that could influence the clinical course and patient management. These abnormalities may not be due to a direct effect of the ingested drug and factors such as stress may play a role.
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Affiliation(s)
- Bruce K Adams
- Department of Nuclear Medicine, Groote Schuur Hospital, Cape Town, South Africa.
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Rodríguez-Landa JF, Contreras CM. A review of clinical and experimental observations about antidepressant actions and side effects produced by Hypericum perforatum extracts. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2003; 10:688-699. [PMID: 14692732 DOI: 10.1078/0944-7113-00340] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Hypericum perforatum is an herbaceous perennial plant, also known as "St. John's wort", used popularly as a natural antidepressant. Although some clinical and experimental studies suggest it has some properties similar to conventional antidepressants, the proposed mechanism of action seems to be multiple: a non-selective blockade of the reuptake of serotonin, noradrenaline and dopamine; an increase in density of serotonergic and dopaminergic receptors and an increased affinity for GABAergic receptors; moreover, the inhibition of monoaminoxidase enzyme activity has been involved. In any case, the increase of monoamine concentrations in the synaptic cleft resembles several actions exerted by clinically effective antidepressants. In the present article, we review some of the controversial evidence derived from clinical and experimental studies suggesting that H. perforatum exerts antidepressant-like actions, and we also review some of its side effects, such as nausea, rash, fatigue, restlessness, photosensitivity, acute neuropathy, and even episodes of mania and serotonergic syndrome when administered simultaneously with other antidepressant drugs. All of the foregoing suggests that H. perforatum extracts appear to exert potentially significant pharmacological activity involving several neurotransmission systems supposed to be involved in the pathophysiology of depression. However, little information regarding the safety of H. perforatum is available, including potential herb-drug interactions. There is a need for additional research on the pharmacological and biochemical activity of H. perforatum, as well as its side-effects and its several bioactive constituents to further elucidate the mechanisms of antidepressant actions.
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Affiliation(s)
- J F Rodríguez-Landa
- Laboratorio de Neurofarmacología, Instituto de Neuroetología, Universidad Veracruzana, México
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Affiliation(s)
- John G Laffey
- Department of Physiology, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
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17
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Affiliation(s)
- Alison Jones
- National Poisons Information Service, Guy's & St Thomas' Hospitals, London, United Kingdom.
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Blackman K, Brown SG, Wilkes GJ. Plasma alkalinization for tricyclic antidepressant toxicity: a systematic review. EMERGENCY MEDICINE (FREMANTLE, W.A.) 2001; 13:204-10. [PMID: 11482860 DOI: 10.1046/j.1442-2026.2001.00213.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review the evidence that plasma alkalinization improves the outcome in tricyclic antidepressant toxicity. METHODS Medline search from 1966 to October 2000 (articles in all languages were included) and examination of bibliographies. Published papers including animal studies, in vitro studies, human case reports, case series and retrospective studies were reviewed. RESULTS Our search identified 115 publications, all of which were retrieved. Human studies included eight case reports, four case series, one controlled study and two retrospective chart reviews. No randomized controlled human trials were found. Twelve animal studies were identified that investigated pH manipulation or saline load and their effects on physiological parameters in tricyclic antidepressant toxicity. CONCLUSIONS The practice of alkalinization for tricyclic antidepressant toxicity is based on animal studies, case reports and opinion. The mechanism of action appears to be multifaceted and may vary between different tricyclic antidepressants. Significant interspecies variation makes extrapolation from animal studies to humans difficult. Alkalinization therapy appears reasonable in patients with compromising dysrhythmias and shock when supportive interventions have been ineffective; however, the available evidence does not support prophylactic alkalinization in the absence of life-threatening cardiovascular toxicity.
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Affiliation(s)
- K Blackman
- Department of Emergency Medicine, Royal Hobart Hospital, Hobart Tasmania, Australia.
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Darcy P, Dredge K, Kellehir P, Kelly JP, Leonard BE, Chambers PL. Acute toxicity profile of maprotiline in the rat. PHARMACOLOGY & TOXICOLOGY 1999; 85:276-81. [PMID: 10628903 DOI: 10.1111/j.1600-0773.1999.tb02022.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of the present study was to examine the toxic effects of single oral administrations of the antidepressant maprotiline at 150 mg/kg or 300 mg/kg using female Sprague-Dawley rats. Body-weight gain was significantly reduced in the group receiving 300 mg/kg on days 1-5 of the study (P<0.01). A significant reduction in food and water intake was observed on days 1 and 2 of the study (P<0.01) in the 300 mg/kg group and on day 1 in the 150 mg/kg group (P<0.05). There was a significant decrease in nocturnal home cage activity over the first five days of the study in the 300 mg/kg group (P<0.01). A significant hypothermic response was observed in both 150 and 300 mg/kg groups at 1, 2 and 4 hr after dosing (P<0.01), that had returned to control values within 8 hr following administration. This study demonstrates that a multi-parameter approach is appropriate for the investigation of high doses of antidepressants in rodents.
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Affiliation(s)
- P Darcy
- Department of Pharmacology, National University of Ireland, Galway.
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Dahlin KL, Bohlin K, Strindlund J, Ryrfeldt A, Cotgreave IA. Amitriptyline-induced loss of tight junction integrity in a human endothelial--smooth muscle cell bi-layer model. Toxicology 1999; 136:1-13. [PMID: 10499846 DOI: 10.1016/s0300-483x(99)00035-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Tricyclic antidepressants can, when taken in overdose, cause serious pulmonary failure such as the adult respiratory distress syndrome (ARDS). In this study we have examined the effects of some tricyclic antidepressants (amitriptyline, imipramine, nortriptyline and desipramine) on the viability and morphology of human endothelial and smooth muscle cells derived from umbilical cord. Effects of amitriptyline on endothelial cell fluidity, as well as permeability changes to an endothelial-smooth muscle cell bi-layer, were also studied. The tricyclic antidepressants induced acute, sub-lethal toxicity in both cell types above 100 microM as assessed by the MTT reduction assay. Morphological changes were also observed at these concentrations. Such changes were, however, absent at 33 microM and below. Amitriptyline did, however, cause a concentration-dependent fall in the electrical resistance of an endothelial-smooth muscle cell bi-layer, with significant effects already evident at 33 microM. All of these observed effects were fairly rapid and appeared within 5-15 min of exposure. The rapidity of these permeabilisation effects suggests potential membrane perturbations, since tricyclic antidepressants are lipophilic molecules with affinity for cell membranes. However, fluorescence anisotropy measurements showed no significant difference in membrane fluidity between amitriptyline-treated and control endothelial cells. Collectively, these data point to specific mechanisms of action of amitriptyline, and probably also the other tricyclic antidepressants studied, on endothelial permeability, which is a hallmark of ARDS. The data suggest that increased endothelial permeability could be due to impaired tight junction function.
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MESH Headings
- Amitriptyline/toxicity
- Antidepressive Agents, Tricyclic/toxicity
- Cell Membrane Permeability/drug effects
- Cell Survival/drug effects
- Cells, Cultured
- Coculture Techniques
- Desipramine/toxicity
- Electric Impedance
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/pathology
- Fluorescent Antibody Technique, Indirect
- Formazans/metabolism
- Humans
- Imipramine/toxicity
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/pathology
- Nortriptyline/toxicity
- Spectrometry, Fluorescence
- Tetrazolium Salts/metabolism
- Tight Junctions/drug effects
- Tight Junctions/physiology
- Umbilical Cord/cytology
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Affiliation(s)
- K L Dahlin
- Division of Inhalation Toxicology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Nahas GG, Sutin KM, Fermon C, Streat S, Wiklund L, Wahlander S, Yellin P, Brasch H, Kanchuger M, Capan L, Manne J, Helwig H, Gaab M, Pfenninger E, Wetterberg T, Holmdahl M, Turndorf H. Guidelines for the treatment of acidaemia with THAM. Drugs 1998; 55:191-224. [PMID: 9506241 DOI: 10.2165/00003495-199855020-00003] [Citation(s) in RCA: 123] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
THAM (trometamol; tris-hydroxymethyl aminomethane) is a biologically inert amino alcohol of low toxicity, which buffers carbon dioxide and acids in vitro and in vivo. At 37 degrees C, the pK (the pH at which the weak conjugate acid or base in the solution is 50% ionised) of THAM is 7.8, making it a more effective buffer than bicarbonate in the physiological range of blood pH. THAM is a proton acceptor with a stoichiometric equivalence of titrating 1 proton per molecule. In vivo, THAM supplements the buffering capacity of the blood bicarbonate system, accepting a proton, generating bicarbonate and decreasing the partial pressure of carbon dioxide in arterial blood (paCO2). It rapidly distributes through the extracellular space and slowly penetrates the intracellular space, except for erythrocytes and hepatocytes, and it is excreted by the kidney in its protonated form at a rate that slightly exceeds creatinine clearance. Unlike bicarbonate, which requires an open system for carbon dioxide elimination in order to exert its buffering effect, THAM is effective in a closed or semiclosed system, and maintains its buffering power in the presence of hypothermia. THAM rapidly restores pH and acid-base regulation in acidaemia caused by carbon dioxide retention or metabolic acid accumulation, which have the potential to impair organ function. Tissue irritation and venous thrombosis at the site of administration occurs with THAM base (pH 10.4) administered through a peripheral or umbilical vein: THAM acetate 0.3 mol/L (pH 8.6) is well tolerated, does not cause tissue or venous irritation and is the only formulation available in the US. In large doses, THAM may induce respiratory depression and hypoglycaemia, which will require ventilatory assistance and glucose administration. The initial loading dose of THAM acetate 0.3 mol/L in the treatment of acidaemia may be estimated as follows: THAM (ml of 0.3 mol/L solution) = lean body-weight (kg) x base deficit (mmol/L). The maximum daily dose is 15 mmol/kg for an adult (3.5L of a 0.3 mol/L solution in a 70kg patient). When disturbances result in severe hypercapnic or metabolic acidaemia, which overwhelms the capacity of normal pH homeostatic mechanisms (pH < or = 7.20), the use of THAM within a 'therapeutic window' is an effective therapy. It may restore the pH of the internal milieu, thus permitting the homeostatic mechanisms of acid-base regulation to assume their normal function. In the treatment of respiratory failure, THAM has been used in conjunction with hypothermia and controlled hypercapnia. Other indications are diabetic or renal acidosis, salicylate or barbiturate intoxication, and increased intracranial pressure associated with cerebral trauma. THAM is also used in cardioplegic solutions, during liver transplantation and for chemolysis of renal calculi. THAM administration must follow established guidelines, along with concurrent monitoring of acid-base status (blood gas analysis), ventilation, and plasma electrolytes and glucose.
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Affiliation(s)
- G G Nahas
- Department of Anaesthesiology, New York University Medical Center, New York, USA.
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Fiedler MA, Biddle C. Review of chemical, medication, and anesthesia toxicity in the OR. AORN J 1998; 67:398, 401-6, 409-11. [PMID: 9505120 DOI: 10.1016/s0001-2092(06)62887-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A host of toxic substances exist in the OR. The toxicity of prep solutions, cleaning chemicals, common medications, and trace anesthetic gases varies greatly. Nurses use, direct others in the use of, or administer potential toxins while breathing air that may be contaminated to some degree with anesthetic vapors. Often, the OR nurse is the neighborhood resource when questions about the toxicity of common chemicals and drugs arise. A general knowledge of the toxicity of these substances improves the nurse's ability to assess the risk from trace anesthetic gases, prevent injury to patients, provide first aid when potentially dangerous exposure occurs, and direct others in the safe use of OR chemicals.
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Affiliation(s)
- M A Fiedler
- School of Health Related Professions, University of Alabama at Birmingham, USA
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Dahlin KL, Lâstbom L, Blomgren B, Ryrfeldt A. Acute lung failure induced by tricyclic antidepressants. Toxicol Appl Pharmacol 1997; 146:309-16. [PMID: 9344899 DOI: 10.1006/taap.1997.8255] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Overdosing of several drugs, such as tricyclic antidepressants, salicylates, and opiates, is known to induce effects like those seen in patients with adult respiratory distress syndrome. By exposing isolated perfused and ventilated rat lungs via the perfusate to six different tricyclic antidepressants (amitriptyline, nortriptyline, imipramine, desipramine, mianserine, and maprotiline), we investigated possible effects on ventilation (conductance and dynamic compliance), lung perfusion flow, and edema formation. The effects of these substances were pronounced and appeared within 15 min after exposure. Amitriptyline was studied in greater detail and caused a dose-related (0.01-1.0 mM) reduction in ventilation and perfusion flow. At the highest drug concentration pronounced lung edema was observed. Morphological studies were conducted with a transmission electron microscope. The microscopic preparations showed dose-related edema (amitriptyline 0.1 and 1.0 mM). The effects noted in our experimental studies are similar to those described in patients who have taken an overdose of tricyclic antidepressants. This emphasizes the possibility of a noncardiogenic edema component in these patients.
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Affiliation(s)
- K L Dahlin
- Institute of Environmental Medicine, Karolinska Institutet, S-171 77, Sweden
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Sandeman DJ, Alahakoon TI, Bentley SC. Tricyclic poisoning--successful management of ventricular fibrillation following massive overdose of imipramine. Anaesth Intensive Care 1997; 25:542-5. [PMID: 9352770 DOI: 10.1177/0310057x9702500516] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Serious complications from tricyclic antidepressant (TCA) overdose are uncommon. We present a case of massive imipramine overdose complicated by ventricular fibrillation and a prolonged period of cardiovascular collapse. A total of 400 mmol of sodium bicarbonate, 5 mg of adrenaline and 80 mg of sotalol were given during 50 minutes of cardiac arrest. The patient made a full recovery with no apparent neurological sequelae. The highest TCA plasma level we could find in the published literature was 4873 ng/ml4; our patient's peak TCA level was 6000 ng/ml. Tricyclic antidepressant overdose is a common cause of intensive care unit admission. It has a low mortality rate.
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Affiliation(s)
- D J Sandeman
- Department of Anaesthesia, Wollongong Hospital, N.S.W
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Abstract
Antidepressant drugs are currently the mainstay of treatment for all but the mildest forms of depression. Their effectiveness in the management of depressive illness is undisputed and their effectiveness in preventing suicide, while not proven, may be assumed. Nevertheless, of all the drugs that are taken in lethal overdose, prescribed antidepressants are among the most common. Epidemiological studies from several countries have provided evidence of marked differences in overdose toxicity between drug classes and, in some cases, between individual drugs within a class, with some of the older tricyclic antidepressants (TCAs) being the most toxic. Over 80% of all deaths arising from overdose of antidepressant medication in the UK between 1987 and 1992 were caused by 2 drugs: amitriptyline and dothiepin. Taken alone, this figure conveys little information about the toxicity of either drug. However, when considered within an epidemiological context, the evidence suggests that both drugs are highly toxic in overdose, a conclusion that is supported by animal studies of the toxicity of TCAs and by clinical evidence of overdose toxicity. This paper reviews the epidemiological evidence concerning the acute toxicity of antidepressant drugs and considers the interplay of factors that contribute to the toxicity which occurs when they are taken in acute overdose. The inherent toxicity of the drug appears to be the crucial factor and, although less well researched, prescribing practices and perception of toxicity are probable contributory factors.
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Affiliation(s)
- J A Henry
- Accident and Emergency Department, St Mary's Hospital, London, England
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Abstract
OBJECTIVE To report a case of pulmonary edema due to dibenzepin overdose. CASE SUMMARY A 39-year-old woman was hospitalized 24 hours after she ingested eight tablets of dibenzepin hydrochloride delayed-release 240 mg/tablet (approximately 35 mg/kg body weight). On admission the patient was confused, and physical examination revealed sinus tachycardia (HR 130 beats/min). Forty-five hours after ingestion of the dibenzepin she developed pulmonary edema and was treated with furosemide, morphine, and mechanical ventilation through an endotracheal tube for 48 hours. Repeated echocardiography revealed left ventricular dysfunction that resolved as the medical condition of the patient improved. Appropriate studies excluded pneumonia, pneumonitis, adult respiratory distress syndrome, myocardial infarction, and pulmonary emboli as contributing factors to this patient's condition. DISCUSSION Tricyclic antidepressant overdose is known to cause cardiopulmonary complications, including pulmonary edema. To the best of our knowledge, this is the first reported case of pulmonary edema as a result of dibenzepin overdose. The most probable mechanism for this complication is depression of the left ventricular function. CONCLUSIONS As with other tricyclic antidepressants, dibenzepin toxicity may cause pulmonary edema. Close patient monitoring is essential for at least 48-72 hours after the overdose.
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Affiliation(s)
- E Wirtheim
- Department of Internal Medicine A, Beilinson Medical Center, Petach Tikva, Israel
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Taboulet P, Michard F, Muszynski J, Galliot-Guilley M, Bismuth C. Cardiovascular repercussions of seizures during cyclic antidepressant poisoning. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1995; 33:205-11. [PMID: 7760443 DOI: 10.3109/15563659509017985] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cyclic antidepressant overdose involves a risk of generalized seizures and cardiovascular disturbances. We have conducted a retrospective study to test the hypothesis of a relationship between generalized seizures and the onset of arrhythmia, hypotension or cardiac arrest during cyclic antidepressant intoxication. Patients who had seizures after ingestion of toxic amounts of tri- or tetracyclic antidepressants were included. Limb-lead QRS complex duration and systolic blood pressure were recorded before and after seizure. Twenty-four of the 388 patients (6.2%) who were admitted to our ICU over a four-year period had seizures (2.3 +/- 2 seizures/patient). Cardiac repercussions of cyclic-induced seizure were frequent and severe. In the postictal period, broadening of the QRS duration or hypotension occurred or were exacerbated in at least 41% and 29% of cases, respectively. In three patients (12.5%), the seizure-induced cardiovascular state was life-threatening and required massive alkalinization therapy and vasopressors, and two of the three required cardiac massage or cardioversion. Prior to seizure, these three patients had severe intoxications characterized by QRS duration > or = 120 ms and systolic blood pressure < or = 80 mm Hg. The results of this work confirm the potential risk of cardiovascular deterioration after cyclic antidepressant-induced seizure and raise the question of a prophylactic approach especially towards the subgroup with unstable hemodynamic status.
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Affiliation(s)
- P Taboulet
- Hôpital Fernand Widal, University Paris VII, France
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Lipper B, Gaynor BD. Value of serum tricyclic antidepressant levels with massive nortriptyline overdose and persistent hypotension. Am J Emerg Med 1995; 13:107. [PMID: 7832932 DOI: 10.1016/0735-6757(95)90272-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Larkin GL, Graeber GM, Hollingsed MJ. Experimental amitriptyline poisoning: treatment of severe cardiovascular toxicity with cardiopulmonary bypass. Ann Emerg Med 1994; 23:480-6. [PMID: 8135422 DOI: 10.1016/s0196-0644(94)70066-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE To compare cardiopulmonary bypass (CPB) with more conventional therapy in the treatment of severe amitriptyline poisoning. DESIGN Prospective, randomized, controlled, laboratory investigation. INTERVENTIONS Profound cardiovascular toxicity was induced in 20 anesthetized Yorkshire swine (72 +/- 8.3 kg) by amitriptyline infusion at 0.5 mg/kg/min. Ventilation was adjusted to keep arterial pH at 7.50 +/- 0.05 and the PCO2 at 35 mm Hg. The swine were randomized in a 1:1 ratio to one of two groups, CPB or control. Both groups received amitriptyline infusion until they experienced near-lethal toxicity, defined as a systolic blood pressure below 30 mm Hg for one minute. The control group was then given supportive treatment, including IV fluids, sodium bicarbonate, vasopressors, and standard pharmacologic (advanced cardiac life support) interventions. Control animals failing to respond to supportive measures after five minutes were given open-chest cardiac massage for 30 minutes or until the return of spontaneous circulation. The CPB group received only mechanical support by CPB for 90 to 120 minutes. No sodium bicarbonate, antiarrhythmics, or cardiotonic agents were provided to the CPB group during this resuscitation. RESULTS All 20 animals experienced cardiac conduction delays, dysrhythmias, and progressive hypotension within 30 minutes of receiving IV amitriptyline at 0.5 mg/kg/min. The ten swine receiving CPB as treatment for cardiovascular toxicity were able to completely correct the dysrhythmias, cardiac conduction abnormalities, and hypotension produced by the amitriptyline; however, only one of ten control animals could be resuscitated (P = .0001). Nine of ten swine treated with CPB were easily weaned off bypass without any pharmacologic intervention; however, one required norepinephrine to be weaned. All 11 resuscitated swine were able to be salvaged. CONCLUSION CPB improved survival in our swine model of severe amitriptyline poisoning.
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Affiliation(s)
- G L Larkin
- Department of Surgery, West Virginia University, Morgantown
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Roberge RJ, Martin TG, Hodgman M, Benitez JG. Acute chemical pancreatitis associated with a tricyclic antidepressant (clomipramine) overdose. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1994; 32:425-9. [PMID: 8057402 DOI: 10.3109/15563659409011044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A case of acute chemical pancreatitis and associated prolonged ileus following an acute overdose of the tricyclic antidepressant clomipramine by an adult is reported. Pancreatitis is a rarely-reported serious complication of antidepressant overdose and may lead to prolonged ileus and extended hospitalization.
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Affiliation(s)
- R J Roberge
- University of Pittsburgh Medical Center, PA 15213
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Shannon MW. Duration of QRS disturbances after severe tricyclic antidepressant intoxication. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1992; 30:377-86. [PMID: 1512811 DOI: 10.3109/15563659209021553] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
While the clinical toxicity of tricyclic antidepressants, particularly the development of seizures and arrhythmias, has been strongly correlated with a QRS interval of greater than or equal to 100 msec on electrocardiography, the resolution pattern of QRS abnormalities remains poorly defined. We prospectively monitored 22 consecutive patients who were referred to a regional poison center after a tricyclic antidepressant ingestion associated with a QRS interval of greater than 100 msec. An ECG was obtained every 6-8 h in all patients until the QRS interval was less than 100 msec. Among enrolled patients the mean maximal QRS interval was 145 msec. Ten patients (45.5%) developed seizures while 6 (27%) developed cardiac arrhythmias. The time from ingestion to the last ECG demonstrating a widened QRS interval was a median 12.3 h (range 1-70 h); the time from ingestion to the first ECG with a QRS less than 100 msec was a median 19.3 h (range 3-78 h). No patients developed seizures or life-threatening cardiac arrhythmias after the QRS interval was less than 100 msec. Ten patients received sodium bicarbonate while 12 did not. There were no significant differences in the duration of QRS widening between the two groups. These data suggest that the typical period of QRS prolongation after severe tricyclic antidepressant ingestion is 12-18 h but may be as long 3 d. The factors which determine the duration of QRS widening are unclear. Sodium bicarbonate may not reduce the total duration of QRS disturbances.
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