This handout is for post-cardiac-arrest care — tricyclic antidepressant (tca) overdose. Your care team identified this based on: rosc after tca-overdose cardiac arrest — wide-complex vt / vf rhythm reflecting na-channel blockade with r-on-t phenomenon.
Other reasons your team may use this plan: wide qrs >160 ms with terminal r wave in avr predicts impending vf / seizures in tca od (liebelt 1995 pmid 7775314); witnessed tca ingestion (amitriptyline, nortriptyline, doxepin, imipramine, clomipramine, desipramine) with cardiac arrest — typically intentional self-harm in adult; patient with depression history found collapsed with empty tca pill bottle / suicide note → suspect tca od with high lethality.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| sodium_bicarbonate | 1-2 mEq/kg IV BOLUS for QRS >100 ms or hypotension; THEN infusion 150 mEq in 1 L D5W at 250 mL/h targeting arterial pH 7.45-7.55 + QRS <100 ms | IV | bolus then continuous infusion | AACT/EAPCCT 2011 + Body Emerg Med Australas 2011 — sodium bicarbonate is DEFINITIVE for TCA cardiotoxicity by both alkalosis (improves Na-channel availability) and sodium loading (overcomes blockade); reverses QRS widening + restores BP |
| epinephrine | 1 mg IV q3-5 min during arrest | IV | standard ACLS | AHA 2020 ACLS |
| norepinephrine | 0.05-0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 + AACT — norepinephrine combines α + β agonism to overcome combined α-blockade + cardiogenic depression; phenylephrine pure α-agonist not first-line in TCA |
| lidocaine | 1-1.5 mg/kg IV bolus then 1-4 mg/min infusion | IV | bolus then continuous | AACT — lidocaine is Class IB with less Na-channel blockade than IA/IC; limited evidence but reasonable adjunct in refractory TCA-VT after bicarbonate; AVOID Class IA (procainamide), IC (flecainide), III (amiodarone) |
| lorazepam | 4 mg IV q15 min PRN | IV | PRN | NCS 2012 status epilepticus + AACT — benzodiazepines first-line for TCA seizures; AVOID phenytoin (Class IB Na-channel blocker, additive) |
| diazepam | 5-10 mg IV q15 min PRN | IV | PRN | NCS 2012 — diazepam alternative if lorazepam unavailable |
| lipid_emulsion_20 | 1.5 mL/kg IV BOLUS over 1 min then 0.25 mL/kg/min infusion × 30-60 min | IV | bolus then infusion | ACMT 2017 lipid emulsion guidance — controversial in TCA but reasonable for refractory cardiac arrest unresponsive to bicarbonate; case reports support; mechanism — lipid sink for lipophilic drugs |
| propofol | 5-50 µg/kg/min | IV | continuous; titrate RASS | PADIs 2018 |
| fentanyl | 25-100 µg/h | IV | continuous; titrated | PADIS 2018 — analgesia + shivering suppression for TTM |
| lactated_ringers | 1-1.5 L bolus then 200-500 mL/h titrate UOP 1-2 mL/kg/h | IV | continuous | KDIGO 2012 §5.4 + Bosch 2009 PMID 19571284 — aggressive crystalloid prevents myoglobinuric AKI in rhabdo |
| acetylcysteine | IV 21-h regimen: 150 mg/kg over 1h then 50 mg/kg over 4h then 100 mg/kg over 16h | IV | 21-h infusion | Rumack-Matthew nomogram + AACT — NAC for APAP co-ingestion; TCA + APAP very common combination for self-harm; missed APAP → fulminant hepatic failure 2-4 d later |
| activated_charcoal | 1 g/kg PO/NG (50-100 g adult dose) | PO/NG | one-time | AACT 2005 single-dose AC position — limited benefit beyond 1-2h; consider only if early presentation + airway protected; aspiration risk if AMS without intubation |
Plan: TCA-overdose post-arrest phenotype — sodium bicarbonate-driven resuscitation + AVOIDANCE of Na-channel-blocking antiarrhythmics + post-ROSC standard bundle + psychiatric care
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Inpatient psychiatry admission for involuntary or voluntary commitment; outpatient psychiatry within 7 d of d/c; PCP follow-up for mental health; means restriction counseling (medication storage, lethal-means reduction); SSRI/SNRI substitution discussion if depression treatment ongoing (TCAs no longer first-line for depression given fatal-OD risk); cardiology only if residual structural concern
Guideline: AHA 2020 ACLS / Post-Cardiac-Arrest Care + AACT/EAPCCT 2011 TCA toxicity + ACMT 2017 lipid emulsion + KDIGO 2012 AKI + TTM2 + HYPERION + Sandroni 2021 neuroprog