- local anesthetic agents
- tricyclic antidepressants
- carbamazepine (in very high doses)
- antiarrhythmics e.g. flecainide, quinine
- phenothiazines (not usually clinically significant)
NB. phenytoin and sodium valproate do not usually present with features of sodium channel blockade in overdose.
- CVS: arrhythmias, prolonged PR, QRS widening and secondary QT effects, hypotension, pulmonary oedema
- CNS: mild ataxia -> coma -> seizures, peri-oral numbness/tingling, tinnitus
- drug levels rarely helpful
- ECG: positive QRS in II, dominant R wave in aVR, QRS duration > 100ms
- high anion gap metabolic acidosis
SPECIFIC MANAGEMENT AND TRIGGERS FOR INTERVENTION
- NaHCO3 is the mainstay for QRS >140, cardiotoxicity, seizures
- benzodiazepines for seizures
- activate charcoal: severe OD, one dose after airway secured; MDAC for carbamezepine
- intra-lipid: LA toxicity with ECG changes
- CVVHDF: carbamazepine (alternative to charcoal hemoperfusion)
- ECMO: cardiac arrest
References and Links
- Tox Conundrum – Another TCA Overdose!
- Tox Conundrum – Tricyclic antidepressant toxicity
- ECG Library – Overdose: TCA
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.