This handout is for tricyclic antidepressant overdose. Your care team identified this based on: reported or suspected tca / cyclic antidepressant ingestion (amitriptyline, nortriptyline, imipramine, clomipramine, doxepin, dosulepin) [aact/eapcct; acmt 2024].
Other reasons your team may use this plan: qrs >100 ms or terminal r wave in avr >3 mm on ecg [boehnert & lovejoy nejm 1985; liebelt 1995]; anticholinergic toxidrome + seizure / coma / hypotension cluster [goldfrank 2024]; unexplained wide-complex tachycardia / hypotension after deliberate self-poisoning [acmt 2024].
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, repeat q3–5 min while QRS wide; then infusion 100–150 mEq in 1 L D5W titrated | IV | bolus then continuous | Goldfrank/ACMT 2024 — dual mechanism: sodium load overcomes fast-Na-channel blockade and alkalemia (target arterial pH 7.50–7.55) increases protein binding / favours the non-toxic uncharged drug; titrate to QRS <100 ms, not to a fixed dose |
| hypertonic saline (3%) | 100–250 mL IV | IV | PRN if QRS remains wide despite NaHCO3 and pH at ceiling | ACMT 2024 — when alkalinization is maximised but QRS stays wide, additional sodium loading without further raising pH can narrow the QRS; monitor Na+ closely |
Plan: TCA overdose — serum alkalinization → seizure control → vasopressor → lipid emulsion / ECMO
Call 911 or go to the nearest emergency room right away if you have:
Psychiatry safety plan and means-restriction counselling for intentional ingestion, PCP medication reconciliation (limit TCA dispensed quantity / switch to safer agent), social work, neurology if anoxic injury, cardiology if persistent conduction abnormality [ACMT 2024]
Guideline: AACT/EAPCCT decontamination position papers + Goldfrank's Toxicologic Emergencies 11th ed (cyclic antidepressants) + 2024 ACMT lipid-emulsion workgroup + Boehnert & Lovejoy NEJM 1985 QRS / terminal-R-aVR seizure & arrhythmia thresholds + Liebelt 1995 aVR criterion