This is the current release of the guideline.

Definitions for the weight of the evidence (A-D, Z) and classes of recommendations (1a-6) can be found at the end of the "Major Recommendations" field.

1. Patients with suspected self-harm or who are the victims of malicious administration of a tricyclic antidepressant (TCA) should be referred to an emergency department immediately (Grade D).
2. Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by Emergency Medical Services, with close monitoring of clinical status and vital signs en route, should be considered (Grade D).
3. Patients who are symptomatic (e.g. weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B).
4. Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department:
   • An amount that exceeds the usual maximum single therapeutic dose or
   • An amount equal to or greater than the lowest reported toxic dose

   For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5.0 mg/kg. For desipramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; for protriptyline it is >1.0 mg/kg. This recommendation applies to both patients who are naïve to the specific cyclic antidepressant and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grade B/C).

5. Do not induce emesis (Grade D).
6. The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D).
7. For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C).
8. Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D).
9. An electrocardiogram or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B).
10. Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard advanced cardiac life support (ACLS) guidelines as outlined by the American Heart Association (Grade D).
11. Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D).
12. For TCA-associated convulsions, benzodiazepines are recommended (Grade D).
13. Flumazenil is not recommended for patients with TCA poisoning (Grade D).

Dosage and follow-up recommendations are summarized in Appendix 4 in the original guideline document.

Definitions:

Grades of Recommendation and Levels of Evidence

An algorithm is provided in Appendix 4 of the original guideline document for triage of tricyclic antidepressant ingestion.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2006 Jul 19

American Association of Poison Control Centers - Professional Association

Health Resources and Services Administration, U.S. Department of Health and Human Services

Not stated

Primary Authors: Alan D. Woolf, MD, MPH; Andrew R. Erdman, MD; Lewis S. Nelson, MD; E. Martin Caravati, MD, MPH; Daniel J. Cobaugh, PharmD; Lisa L. Booze, PharmD; Paul M. Wax, MD; Anthony S. Manoguerra, PharmD; Elizabeth J. Scharman, PharmD; Kent R. Olson, MD; Peter A. Chyka, PharmD; Gwenn Christianson, MSN; William G. Troutman, PharmD

Expert Consensus Panel Members: Lisa L. Booze, PharmD, Certified Specialist in Poison Information, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, Maryland; E. Martin Caravati, MD, MPH, FACMT, FACEP, Professor of Surgery (Emergency Medicine) University of Utah, Medical Director, Utah Poison Center, Salt Lake City, Utah; Gwenn Christianson, RN, MSN, Certified Specialist in Poison Information, Indiana Poison Center, Indianapolis, Indiana; Peter A. Chyka, PharmD, FAACT, DABAT, Professor, Department of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee; Daniel J. Cobaugh, PharmD, FAACT, DABAT, Director of Research, ASHP Research and Education Foundation, Bethesda, Maryland, Former Associate Director, American Association of Poison Control Centers; Daniel C. Keyes, MD, MPH, FACEP, FACMT, Medical Director, Pine Bluff Chemical Demilitarization Facility, Associate Professor, Southwestern Toxicology Training Program, Dallas, Texas; Anthony S. Manoguerra, PharmD, DABAT, FAACT, Professor of Clinical Pharmacy and Associate Dean, School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, Former Director, California Poison Control System, San Diego Division, San Diego, California; Lewis S. Nelson, M.D., FACEP, FACMT, Assistant Professor of Emergency Medicine, New York University School of Medicine, Associate Medical Director, New York City Poison Control Center, New York, New York; Kent R. Olson, MD, FACEP, FAACT, FACMT, Medical Director, California Poison Control System, San Francisco Division, Clinical Professor of Medicine & Pharmacy, University of California, San Francisco, San Francisco, California; Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT, Director, West Virginia Poison Center, Professor, West Virginia University School of Pharmacy, Department of Clinical Pharmacy, Charleston, West Virginia; Paul M. Wax, MD, FACMT, Managing Director, Banner Poison Center, Professor of Clinical Emergency Medicine, University of Arizona School of Medicine, Phoenix, Arizona; Alan D. Woolf, MD, MPH, FACMT, Director, Program in Environmental Medicine, Children's Hospital, Boston, Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts

Dr. Booze's husband is employed by AstraZeneca. Dr. Erdman is currently employed by AstraZeneca but was not during his contribution to the development of this guideline. There are no other potential conflicts of interest reported by the expert consensus panel or project staff regarding this guideline.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on November 30, 2006. The information was verified by the guideline developer on December 13, 2006.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.