====== Management of Tricyclic Antidepressant Overdose ======

1. Check pulse, BP, level of coma, 12 lead ECG, arterial blood gases

2. Administer oxygen, establish IV access and start fluids

3. Intubate and ventilate if:

  * Ingestion of > 10 mg/kg with impaired consciousness if < 2 hours since ingestion
  * Any respiratory acidosis or failure
  * Inability to protect airway

4. Decontaminate: Activated charcoal in water 1 g/kg

  * All patients under 2 hours from ingestion.
  * All patients who have intubation indicated in 3

5. Treat Complications

  * a. Acidosis
      * i. Uncomplicated:
        * Sodium bicarbonate 1 mEq/kg bolus (or in adult 50 mEq bolus) and review
      * ii. Complicated by hypotension or QRS >120 msec:
        * Sodium bicarbonate 2 mEq/kg bolus

   * b. Seizures
      * i. Diazepam 0. 1 mg/kg IV as needed. Phenobarbitone infusion (15 mg/kg IV) over 30 min if refractory
      * ii. Check the ECG and acid-base status

  * c. Hypotension
      * i. If QRS < 100 milliseconds
        * 20 mL/kg normal saline stat
        * Feet up Trendelenburg position
      * ii. If QRS >120 msec:
        * Sodium bicarbonate 2 mEq/kg bolus repeated until QRS narrows or pH = 7. 55
        * Give fluid bolus if not already done
      * iii. Volume loading may require 3 to 5 litres in an adult, this is best done with central venous pressure monitoring
      * iv. Consider vasopressors

  * d. Broad complex tachyarrhythmias
      * i. With detectable output
        * Sodium bicarbonate 2 mEq/kg bolus repeated until QRS narrows or pH = 7. 55
      * ii. With no output
        * Sodium Bicarbonate 3 – 6 mEq/kg bolus repeat until pH is 7. 55 or above
        * Standard but prolonged ACLS resuscitation, do not stop until you have a toxicology consultation
      * iii. Other measures
        * Consider [[:wikitox:magnesium_treatment|magnesium]]
        * Overdrive pacing
        * Consider hypertonic saline*

  * e. Broad complex bradyarrhythmias
      * i. With detectable output
        * Sodium bicarbonate 2 mEq/kg bolus repeated until QRS narrows or pH = 7. 55
      * ii. With no output
        * Sodium Bicarbonate 3 – 6 mEq/kg bolus repeat until pH is 7. 55 or above
        * Standard but prolonged ACLS resuscitation, do not stop until you have a toxicology consultation
      * iii. Other measures
        * Consider pacing or isoprenaline
        * Consider hypertonic saline*

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**Hypertonic Saline***

  * Ensure you have achieved a pH of at least 7. 55
  * Give 3 mEq of hypertonic saline as a bolus injection.
  * The role of this treatment is not well defined. Note the clinical effects and report your findings