How is tricyclic antidepressant (TCA) toxicity treated in pediatric patients?

Updated: Mar 18, 2020
  • Author: Derrick Lung, MD, MPH; Chief Editor: Stephen L Thornton, MD  more...
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As with any overdose, good supportive care is the mainstay of treatment and the first priority is to assess and treat any abnormalities in airway, breathing, and circulation (the ABCs). The rapid onset of toxicity from cyclic antidepressant exposures can not be overstated. Early intubation for patients with significant signs of toxicity, including seizures and central nervous system (CNS) depression, is prudent. Patients who are obtunded and those with impending respiratory failure should clearly be intubated for airway protection and ventilatory support. Intravenous fluids should be started for patients who are hypotensive.

During initial evaluation and stabilization, clinicians should bear in mind that symptoms of cyclic antidepressant toxicity generally appear within 2 hours of ingestion. Severe signs of toxicity, such as seizures and dysrhythmias, usually occur within the first 6 hours after ingestion. 

All patients with suspected cyclic antidepressant ingestion should undergo cardiac monitoring for a minimum of 6 hours. Monitoring should continue in symptomatic patients such as those with electrocardiogram (ECG) changes, tachycardia, or mental status changes until the clinical findings have returned to baseline and ECG changes have resolved. Patients may be admitted to a non-ICU ward for telemetry monitoring if they have persistent signs of mild-to-moderate antimuscarinic toxicity (ie, resting tachycardia, mydriasis, behavioral changes, hyperthermia) without serious CNS or cardiac manifestations.

An ECG is performed early to look for a terminal R wave in lead aVR, which is a sign of cyclic antidepressant drug effect that is not necessarily indicative of toxicity. Prolongation of the QRS and development of an R wave in avR are concerning findings and indicative of toxin-induced sodium channel blockade. These changes confirm significant cyclic antidepressant exposure and consequent risk for seizures and dysrhythmias. If seizures do occur, they should be initially treated with benzodiazepines with consideration for sodium bicarbonate therapy.

Patients with severe CNS toxicity or any cardiotoxicity should be admitted to an ICU setting. Patients should be monitored for at least 24 hours until the ECG findings normalize and alkalinization therapy is stopped. Patients with suspected intentional overdose should be screened for suicidal behavior and admitted to a psychiatric facility, if indicated, once they are medically cleared.

Asymptomatic patients should be screened for suicidal intent and admitted to a psychiatric facility as appropriate after an observation period of at least 6 hours. Patients may be discharged from the emergency department (ED) if they meet all of the following criteria:

  • The ingestion was unintentional
  • No signs or symptoms of cyclic antidepressant toxicity are evident during observation for a minimum of 6-8 hours
  • The parents are reliable
  • Appropriate follow-up is assured

All serious pediatric cyclic antidepressant overdoses should be admitted to a pediatric ICU. Transfer may be indicated after the patient has been stabilized if the treating hospital has no such facility. Children with unintentional overdose should be admitted if inadequate supervision in the home is suspected or if adequate follow-up cannot be assured.

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