Order: Poisoning with tricyclic antidepressants
Source: uptodate 2023
Imp: TCA poisoning
Condition: not good
Posi: free
Act: CBR, Bed sides up
Diet: NPO
C.V.S
Please;
1. IV line
2. ECG
Note the increased QRS interval.
3. CM + POM
4. CBC diff, BS Glucometery, B-HCG, Na, K, ABG
For bicarbonate therapy, ABG is needed, the target pH is 7.55-7.55.
In women of childbearing age, request a pregnancy test.
5. Acetaminophen and salicylate levels
6. Consider ABC
7. O2 therapy; until 5 lit/min with nasal cannula or until 10 lit/min with face mask.
8. Serum N.S. 250-500cc IV stat
In case of hypotension, you can repeat the serum dose.
In case of hypotension resistant to treatment with serum and bicarbonate, even give a vasopressor (such as neosynephrine or norepinephrine).
9. Serum Saline 3% 100 mL IV stat. if symptoms persist, 2 or more doses can be given at 10 minutes intervals.
In case of hypotension resistant to treatment with normal saline and bicarbonate and vasopressor
10. Sodium bicarbonate 2-3 mEq/kg up to 150mEq IV push and assess for QRS narrowing.
If QRS narrows, begin 150mEq of sodium bicarbonate in 1 liter of D5W IV infusion to run at 250mL/h in adults or twice the maintenance fluid rate in children.
In cardiac toxicity, give sodium bicarbonate if the QRS interval is more than 100 msec.
11. Activated Charcoal 1g/kg (Max dose: 50g).
Give alertness in patients.
* Indications for prescribing activated charcoal:
A. Up to 2 hours after taking TCA
b. The presence of digestive complications such as obstruction and ileus
12. Diazepam 5mg Amp IV stat or Lorazepam 2mg Amp IV stat.
Give if seizure/agitation occurs.
Lorazepam dose in agitation is 1mg.
In agitation, benzodiazepine can be repeated at intervals of 5-10 minutes.
Do not give phenytoin in a seizure.
Lotirastam is not recommended for seizures.
13. Mg 1-2 g over 15 minutes or faster, if the patient is in cardiac arrest.
In case of arrhythmia that did not respond to bicarbonate therapy.
14. Lidocaine 1-1.5 mg/kg IV stat then, 1-4 mg/min IV infusion.
In case of arrhythmia that did not respond to bicarbonate therapy.
15. IV bolus of 1-1.5 mL/kg of a 20% lipid emulsion solution given over 1 min.
The same dose may be repeated in cases of cardiac arrest q3-5mins, for a total of 3 bolus doses.
Following the initial bolus, an infusion is started at a rate of 0.025 mL/kg/min until hemodynamic recovery occurs.
In the event that hemodynamic instability persists, the drip may be continued for 1 hour, with a maximum dose of 8 mL/kg over that hour and 12.5 mL/kg in a 24-hour span.
16. Consider cardiac pacing.
In cases of junctional bradycardia following the use of imipramine
17. A resuscitation trolley should be on the patient’s bed.
18. Visit/consultation of respected emergency medicine, toxicology, internal medicine and neurology services if necessary
* Administration of these drugs in patients with TCA poisoning is contraindicated: flumazenil, physostigmine, procainamide, flecainide
Administration of these drugs in patients with TCA poisoning is not recommended: amiodarone, phenytoin
@PARASTAARAN