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cardio.post-arrest.tca-overdose.v1PRODUCTION
cardio.post-arrest.tca-overdose.v1

Post-cardiac-arrest care — tricyclic antidepressant (TCA) overdose

cardiologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

TCA-overdose cardiac arrest — Na-channel blockade → QRS widening → R-on-T → VF; multi-mechanism toxidrome (Na-block + K-block + α-block + anticholinergic + CNS); SODIUM BICARBONATE is DEFINITIVE for cardiotoxicity; AVOID Class IA/IC/III antiarrhythmics; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog and integrate suicide risk + psychiatric care

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TCA etiology + co-ingestant screen + initial rhythm documented

Patient inputs (22)

Older patients have higher mortality; informs prognosis discussion + ICU-care intensity

Agent identification (amitriptyline vs doxepin vs nortriptyline) and estimated dose (≥10× daily dose lethal); informs duration of monitoring given Vd

Activated charcoal candidacy (<2 h post-ingestion + airway protected); peak toxicity 4–6 h; redistribution from tissues 24–72 h

Mixed OD common — acetaminophen (TCA + APAP common combo for self-harm) → check serum APAP level; benzodiazepine → augments sedation; alcohol → augments cardiotoxicity; SSRI → serotonin syndrome layered

TCA OD is nearly always intentional self-harm in adult population; mandates psychiatry consultation + 1:1 sitter + means restriction counseling

Prolonged down-time → rhabdomyolysis from positional injury + seizure + worse hypoxic-ischemic encephalopathy + lower ROSC sustainability

Witnessed + bystander CPR + low-flow time → favorable neuro prognosis; CAHP/OHCA score inputs

VF / wide-complex VT most common with TCA OD (Na-channel blockade + R-on-T); pulseless asystole reflects late terminal phase

CPR duration → ECPR eligibility (INCEPTION PMID 36720130); neuro prognosis weighting

AKI risk from rhabdomyolysis + hypoperfusion; KDIGO 2012 staging

QRS width is the central decision variable: >100 ms = bicarbonate indicated; >160 ms predicts seizures + VF; terminal R-wave in aVR specific for TCA toxicity (Bradberry); QTc for torsades risk; serial ECG q15-30 min initially then q4-6 h × 48 h for redistribution

Hypoxic myocardial injury post-arrest produces troponin elevation; rule out concurrent type-1 MI

Mandatory co-ingestant screen in any intentional OD; TCA + APAP very common combination; missed APAP OD → fulminant hepatic failure 2-4 d later

Down-time + seizures → rhabdomyolysis → myoglobinuric AKI; CK >5000 high-risk threshold (Bosch 2009 PMID 19571284)

Tissue hypoperfusion + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438)

Severe metabolic acidosis common; bicarbonate therapy targets pH 7.45-7.55 — ABG-driven

Aspiration pneumonitis from AMS; pneumothorax from CPR; baseline for ARDS evolution

MAP ≥65 target post-ROSC; hypotension common from α-adrenergic blockade + cardiogenic depression

TTM target 33–37.5 °C × 24h; anticholinergic toxicity may produce hyperthermia requiring active cooling

Avoid hyperoxia: SpO2 92–98%; aspiration risk from AMS

Confirms TCA exposure; not always available; not used to guide therapy (clinical + ECG drives); elevated levels >1000 ng/mL high lethality marker

LV/RV function for post-arrest stunning; rule out concurrent ischemic precipitant if ECG concern

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateningqrs_above_160_ms_predicts_seizures_and_vf
    QRS >160 ms on post-ROSC ECG in TCA OD patient — predicts ongoing seizures and ventricular dysrhythmia (Liebelt 1995 PMID 7775314)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_vf_unresponsive_to_bicarbonate_lipid
    Cardiac arrest with refractory VF unresponsive to standard ACLS + sodium bicarbonate + lipid emulsion in TCA OD patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereseizures_with_rhabdomyolysis_in_tca_overdose
    Seizures (10-20% of severe TCA OD) with subsequent rhabdomyolysis (CK >5000) and AKI risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuicide_risk_with_repeated_overdose_or_known_oud_co_morbidity
    TCA OD survivor with prior overdose attempt history OR known co-morbid substance use disorder requiring intensive psychiatric + addiction medicine intervention
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

TCA-overdose post-arrest phenotype — sodium bicarbonate-driven resuscitation + AVOIDANCE of Na-channel-blocking antiarrhythmics + post-ROSC standard bundle + psychiatric care
axis: tca_overdose_post_arrest_phenotype
Selected axis "TCA-overdose post-arrest phenotype — sodium bicarbonate-driven resuscitation + AVOIDANCE of Na-channel-blocking antiarrhythmics + post-ROSC standard bundle + psychiatric care" by default fallback (first axis)
  • sodium_bicarbonate
    first line
    alkalinizing_agent
    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
    triggers: tca_overdose_with_qrs_above_100ms, tca_overdose_with_hypotension, tca_overdose_with_arrhythmia, tca_overdose_with_seizures
    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
    rxcui 36676
  • epinephrine
    first line
    inotrope_chronotrope_vasopressor
    1 mg IV q3-5 min during arrest • IV • standard ACLS
    triggers: cardiac_arrest, vf_or_pulseless_vt
    AHA 2020 ACLS
    rxcui 3992
  • norepinephrine
    first line
    vasopressor_alpha1_beta1
    0.05-0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: post_rosc_hypotension, tca_alpha_blockade_vasodilation
    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
    rxcui 7512
  • lidocaine
    second line
    class_ib_antiarrhythmic
    1-1.5 mg/kg IV bolus then 1-4 mg/min infusion • IV • bolus then continuous
    triggers: refractory_vt_after_bicarbonate_in_tca_overdose
    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)
    rxcui 142440
  • lorazepam
    first line
    benzodiazepine
    4 mg IV q15 min PRN • IV • PRN
    triggers: tca_seizures, agitation_in_tca_overdose
    NCS 2012 status epilepticus + AACT — benzodiazepines first-line for TCA seizures; AVOID phenytoin (Class IB Na-channel blocker, additive)
    rxcui 6470
  • diazepam
    first line
    benzodiazepine
    5-10 mg IV q15 min PRN • IV • PRN
    triggers: tca_seizures
    NCS 2012 — diazepam alternative if lorazepam unavailable
    rxcui 3322
  • lipid_emulsion_20
    second line
    lipid_rescue
    1.5 mL/kg IV BOLUS over 1 min then 0.25 mL/kg/min infusion × 30-60 min • IV • bolus then infusion
    triggers: refractory_cardiac_arrest_in_tca_overdose, unresponsive_to_bicarbonate
    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
    rxcui 9949
  • propofol
    first line
    sedative_iv_anesthetic
    5-50 µg/kg/min • IV • continuous; titrate RASS
    triggers: post_rosc_intubation_ttm
    PADIs 2018
    rxcui 8782
  • fentanyl
    first line
    opioid_analgesic
    25-100 µg/h • IV • continuous; titrated
    triggers: post_rosc_intubation_ttm_with_pain, shivering_control
    PADIS 2018 — analgesia + shivering suppression for TTM
    rxcui 4337
  • lactated_ringers
    first line
    crystalloid_resuscitation_fluid
    1-1.5 L bolus then 200-500 mL/h titrate UOP 1-2 mL/kg/h • IV • continuous
    triggers: rhabdomyolysis_from_seizures_or_down_time, shock_with_perfusion_deficit
    KDIGO 2012 §5.4 + Bosch 2009 PMID 19571284 — aggressive crystalloid prevents myoglobinuric AKI in rhabdo
  • acetylcysteine
    first line
    antidote_n_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
    triggers: acetaminophen_co_ingestion_above_rumack_matthew_treatment_line
    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
    rxcui 197
  • activated_charcoal
    add on
    gi_decontamination
    1 g/kg PO/NG (50-100 g adult dose) • PO/NG • one-time
    triggers: tca_ingestion_within_2h_with_protected_airway
    AACT 2005 single-dose AC position — limited benefit beyond 1-2h; consider only if early presentation + airway protected; aspiration risk if AMS without intubation
    rxcui 272

outpatient playbook — drug actions (1)

  1. 1. continue SSRI/SNRI for depression
    rxcui 321988
    per psychiatry maintenance • PO • daily
    trigger: long-term depression treatment
    APA depression guideline — SSRI/SNRI safer than TCA

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after TCA-overdose cardiac arrest — wide-complex VT / VF rhythm reflecting Na-channel blockade with R-on-T phenomenon; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care — tricyclic antidepressant (TCA) overdose** (cardio.post-arrest.tca-overdose.v1).
Phenotype framing: Pure TCA arrest (Na-block VF) vs TCA + concurrent ACS (independent precipitant) vs other Na-channel-blocking toxin (cocaine, diphenhydramine, quetiapine, citalopram, propoxyphene) vs hyperkalemic cardiac arrest (BMP) vs other Na-channel-blocking toxin (e.g., bupropion, hydroxychloroquine)
Scope: TCA-overdose cardiac arrest — Na-channel blockade → QRS widening → R-on-T → VF; multi-mechanism toxidrome (Na-block + K-block + α-block + anticholinergic + CNS); SODIUM BICARBONATE is DEFINITIVE for cardiotoxicity; AVOID Class IA/IC/III antiarrhythmics; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog and integrate suicide risk + psychiatric care

No severity triggers fired against current inputs.

Plan

Regimen axis: **TCA-overdose post-arrest phenotype — sodium bicarbonate-driven resuscitation + AVOIDANCE of Na-channel-blocking antiarrhythmics + post-ROSC standard bundle + psychiatric care**.
1. 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 (alkalinizing_agent, first line) — 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
2. epinephrine 1 mg IV q3-5 min during arrest IV standard ACLS (inotrope_chronotrope_vasopressor, first line) — AHA 2020 ACLS
3. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha1_beta1, first line) — 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
4. lidocaine 1-1.5 mg/kg IV bolus then 1-4 mg/min infusion IV bolus then continuous (class_ib_antiarrhythmic, second line) — 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)
5. lorazepam 4 mg IV q15 min PRN IV PRN (benzodiazepine, first line) — NCS 2012 status epilepticus + AACT — benzodiazepines first-line for TCA seizures; AVOID phenytoin (Class IB Na-channel blocker, additive)
6. diazepam 5-10 mg IV q15 min PRN IV PRN (benzodiazepine, first line) — NCS 2012 — diazepam alternative if lorazepam unavailable
7. 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 (lipid_rescue, second line) — 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
8. propofol 5-50 µg/kg/min IV continuous; titrate RASS (sedative_iv_anesthetic, first line) — PADIs 2018
9. fentanyl 25-100 µg/h IV continuous; titrated (opioid_analgesic, first line) — PADIS 2018 — analgesia + shivering suppression for TTM
10. lactated_ringers 1-1.5 L bolus then 200-500 mL/h titrate UOP 1-2 mL/kg/h IV continuous (crystalloid_resuscitation_fluid, first line) — KDIGO 2012 §5.4 + Bosch 2009 PMID 19571284 — aggressive crystalloid prevents myoglobinuric AKI in rhabdo
11. 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 (antidote_n_acetylcysteine, first line) — 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
12. activated_charcoal 1 g/kg PO/NG (50-100 g adult dose) PO/NG one-time (gi_decontamination, add on) — AACT 2005 single-dose AC position — limited benefit beyond 1-2h; consider only if early presentation + airway protected; aspiration risk if AMS without intubation

Setting playbook (outpatient) — Long-term psychiatric + primary care + mental health surveillance; medication management with safer agents (SSRI/SNRI); harm reduction (means restriction); substance use treatment if applicable; cardiology surveillance only if residual structural cardiac concern
13. continue SSRI/SNRI for depression per psychiatry maintenance PO daily — long-term depression treatment (APA depression guideline — SSRI/SNRI safer than TCA)

Non-pharmacologic actions:
- Means restriction maintenance long-term
- Mental health long-term
- Primary care for chronic disease management
- Family CPR maintenance
- Substance use treatment engagement if applicable

AVOID / contraindication checks:
- AVOID_class_IA_antiarrhythmics_procainamide_quinidine_disopyramide (additive Na channel blockade)
- AVOID_class_IC_antiarrhythmics_flecainide_propafenone (additive Na channel blockade)
- AVOID_class_III_antiarrhythmics_amiodarone_sotalol (additive QT prolongation)
- AVOID_phenytoin_for_seizures (Class IB Na channel blocker; additive)
- AVOID_phenylephrine_pure_alpha_agonist_in_tca_hypotension (does not overcome combined α blockade + cardiogenic depression; norepinephrine preferred)
- AVOID_flumazenil_in_mixed_overdose_with_benzo_dependence (seizure risk)
- Nephrotoxic_drug_avoid_evolving_aki (KDIGO 2012)
- Decision:treat_QRS_above_100ms_with_bicarbonate_bolus (AACT 2011)
- Decision:lipid_emulsion_for_refractory_cardiac_arrest_only (ACMT 2017)
- Decision:VA_ECMO_for_refractory_vf_unresponsive_to_bicarbonate_lipid (INCEPTION extrapolation)

Monitoring

Regimen monitoring:
- continuous ecg telemetry x 48h for redistribution late arrhythmia (TCA Vd large; tissue redistribution 24-72h)
- serial ecg q4-6h x 48h for qrs qtc evolution (Liebelt 1995 PMID 7775314)
- arterial pH q1h during bicarbonate infusion target 7.45-7.55 (AACT 2011)
- serial troponin q3-6h x 24h (4th UDMI 2018)
- CK q6h until peak then q12h until downtrending (Bosch 2009 PMID 19571284)
- BMP q6h + K + Mg + Ca + bicarb (rhabdo + AKI electrolyte derangement; bicarbonate-induced hypokalemia)
- urine output hourly target 1-2 mL/kg/h (KDIGO 2012 §5.4)
- continuous core temp via bladder or esophageal probe during TTM (TTM2)
- continuous EEG for 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- lactate q2-4h until normalized (SCAI 2022)
- 1:1 sitter throughout admission for suicide risk (psychiatric standard)
- columbia suicide severity scale at admission and pre dc (SAMHSA)

Setting (outpatient) monitoring:
- Quarterly psychiatry visits
- Annual labs — BMP + lipid + A1c + LFTs
- Annual ECG if residual cardiac concern

Follow-up plan: 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
- Close-out criterion: psychiatry + outpatient mental health + means restriction + family education + safety plan booked

Monitoring phase: Continuous telemetry × 48 h (TCA redistribution from tissues over 24-72 h → late re-arrest risk); arterial line; central line; Foley with hourly UOP target 1-2 mL/kg/h; serial ECG q4-6 h × 48 h for QRS / QTc surveillance; CK q6h until peak documented + downtrending; serial troponin + ABG; multimodal neuroprog ≥72h post-rewarm (Sandroni 2021 PMID 33745427); 1:1 sitter throughout

Disposition

Current setting: outpatient — Long-term psychiatric + primary care + mental health surveillance; medication management with safer agents (SSRI/SNRI); harm reduction (means restriction); substance use treatment if applicable; cardiology surveillance only if residual structural cardiac concern

Disposition criteria:
- Long-term continuation; cross-link to cardiology only for residual structural cardiac concern; otherwise primary care + psychiatry + mental health long-term home

Escalation triggers (move to higher acuity):
- Repeat OD → ED + escalated case management
- Medication discontinuation request → psychiatry discussion
- Mental health deterioration → urgent psychiatry
- New suicidality → urgent psychiatric evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] QRS >160 ms on post-ROSC ECG in TCA OD patient — predicts ongoing seizures and ventricular dysrhythmia (Liebelt 1995 PMID 7775314)
- [LIFE_THREATENING] Cardiac arrest with refractory VF unresponsive to standard ACLS + sodium bicarbonate + lipid emulsion in TCA OD patient
- [SEVERE] Seizures (10-20% of severe TCA OD) with subsequent rhabdomyolysis (CK >5000) and AKI risk

Citations

- AHA 2020 ACLS / Post-Cardiac-Arrest Care + AACT/EAPCCT 2011 TCA toxicity + ACMT 2017 lipid emulsion + KDIGO 2012 AKI + TTM2 + HYPERION + Sandroni 2021 neuroprog [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 7775314) [PMID:7775314](https://pubmed.ncbi.nlm.nih.gov/7775314/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 31532382) [PMID:31532382](https://pubmed.ncbi.nlm.nih.gov/31532382/)
- Cited evidence (PMID 33745427) [PMID:33745427](https://pubmed.ncbi.nlm.nih.gov/33745427/)

Last reconciled with current guidelines: 2026-05-15.
References
  • AHA 2020 ACLS / Post-Cardiac-Arrest Care + AACT/EAPCCT 2011 TCA toxicity + ACMT 2017 lipid emulsion + KDIGO 2012 AKI + TTM2 + HYPERION + Sandroni 2021 neuroprog — PMID:33081530
  • Cited evidence (PMID 7775314) — PMID:7775314
  • Cited evidence (PMID 34133859) — PMID:34133859
  • Cited evidence (PMID 31532382) — PMID:31532382
  • Cited evidence (PMID 33745427) — PMID:33745427