Which physical findings are characteristic of tricyclic antidepressant (TCA) toxicity in pediatric patients?

Updated: Mar 18, 2020
  • Author: Derrick Lung, MD, MPH; Chief Editor: Stephen L Thornton, MD  more...
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Physical examination findings relate to the antimuscarinic, cardiovascular, and central nervous system (CNS) effects of cyclic antidepressants. Antimuscarinic effects are typically the first to appear and should raise clinical suspicion of cyclic antidepressant overdose. One suggested aid to help identify and recall severe CA toxicity is the mnemonic "S-A-L-T" (ie, shock, altered mental status, long-QRS interval duration, terminal R wave in aVR). [3]

A targeted physical examination should assess the patient’s vital signs, and a brief neurologic assessment should include pupillary response and a gross motor and sensory examination. Classic symptoms of antimuscarinic syndrome include mydriasis, delirium, dry skin, fever, and flushing. Other antimuscarinic effects may include the following [9] :

  • Xerostomia
  • Blurred vision
  • Urinary retention
  • Hypoactive or absent bowel sounds
  • Myoclonic twitching

Cardiorespiratory assessment and evaluation of the skin for temperature, moisture, and track marks can be done. Cardiovascular effects may include the following [9] :

  • Sinus tachycardia
  • Prolonged QRS and QT intervals
  • Heart block
  • Peripheral vasodilatation
  • Hypotension
  • Cardiogenic shock
  • Ventricular dysrhythmias
  • Asystole

CNS effects may include the following [9] :

  • Drowsiness
  • Extrapyramidal signs
  • Rigidity
  • Ophthalmoplegia
  • Respiratory depression
  • Seizure
  • Coma

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