Summary
Tricyclic antidepressants are among the commonest causes of both non-fatal and fatal drug poisoning in the world. Their toxicity is due to effects on the brain, the heart, the respiratory system and the parasympathetic nervous system. Symptoms usually appear within 4 hours of an overdose and all but the most seriously poisoned patients recover within 24 hours. The most common clinical features are dry mouth, blurred vision, dilated pupils, sinus tachycardia, pyramidal neurological signs, and drowsiness. In severe poisoning, there may be coma, convulsions, respiratory depression, hypotension and a wide range of electrocardiographic (ECG) abnormalities. The most frequent findings on the ECG are prolongation of the PR and QT intervals; the tracing may resemble bundle branch block or supraventricular or ventricular tachycardias.
Treatment of poisoning due to the tricyclic antidepressants is essentially supportive, there being insufficient evidence at present to recommend the use of methods to increase elimination of the drug from the body. Gastric aspiration and lavage should be performed if more than 750mg of drug have been taken. There must be regular monitoring for hypoxia, acidosis and hypokalaemia and these complications should be corrected enthusiastically. Convulsions should be treated with diazepam or chlormethiazole. Muscular paralysis and artificial ventilation should be employed if anticonvulsants are ineffective. Hypotension should be treated firstly by fluid replacement and then with sympathomimetic agents (dopamine or dobutamine). Antiarrhythmic drugs should only be employed if there is evidence of circulatory failure which fails to respond to correction of hypotension. Sodium bicarbonate infusions should be given to cardiotoxic patients who are acidotic and are worth trying even if the patient is not acidotic.
Although physostigmine salicylate will reverse most of the features of tricylic antidepressant poisoning, its effects are short-lived in serious toxicity and it can produce dangerous side effects; physostigmine should therefore be reserved for those patients who have complications of coma or who have resistant cardiotoxicity or convulsions.
Drug screening and quantitative determination of tricylic antidepressant serum concentrations are useful in a minority of patients who have severe, unusual or prolonged symptoms.
Similar content being viewed by others
References
Ahmad S. Management of cardiac complications in tricyclic antidepressant poisoning. Journal of the Royal Society of Medicine 73: 79, 1980
Alajem N, Albagli C. Severe imipramine poisoning in an infant. American Journal of Diseases of Children 103: 702–705, 1962
Alván G. Effect of activated charcoal on plasma levels of nortriptyline after single doses in man. European Journal of Clinical Pharmacology 5: 236–238, 1973
Aquilonius S-M, Hedstrund U. The use of physostigmine as an antidote in tricyclic antidepressant intoxication. Acta Anaesthesiologica Scandinavica 22: 40–45, 1978
Arditti J, David JM, Devèze JL, Jeanette F, Jouglard J. Intoxication aiguë par la maprotiline. Medicine Legale, Toxicologie 23: 59–62, 1980
Arneson GA. A near fatal case of impramine overdosage. American Journal of Psychiatry 117: 934–936, 1961
Asbach HW, Möhring K, Holz F, Schüler HW, Herrman B, et al. Haemodialysis in impramine poisoning? An experimental study. Klinische Wochenschrift 54: 83–87, 1976
Asbach HW, Schuler HW. Amitriptyline and imipramine poisoning in children. British Medical Journal 2: 386–387, 1974
Auclair MC, Gulda O, Lechat P. Analyse électrophysiologique des effets de l’imipramine sur la fibre myocardique ventriculaire. Archives Internationales de Pharmacodynamie et de Therapie 181: 218–231, 1969
Babb SV, Dunlop SR. Case report of sudden and unexpected death after tricyclic antidepressant. American Journal of Psychiatry 142: 275–276, 1985
Bailey DN, van Dyke C, Langou RA, Jatlow PI. Tricyclic antidepressants: plasma levels and clinical findings in overdose. American Journal of Psychiatry 135: 1325–1328, 1978
Bailey RR, Sharma JR, O’Rourke J, Buttimore AL. Haemodialysis and forced diuresis for tricyclic antidepressant poisoning. British Medical Journal 4: 230–231, 1974
Bain DJG, Turner T. Imipramine poisoning. Archives of Disease in Childhood 46: 887, 1971
Bakke OM, Iversen BM, Willassen Y. Haemoperfusion in treatment of drug intoxication. British Medical Journal 1: 175, 1978
Baldessarini RJ, Gelenberg AJ. Using physostigmine safely. American Journal of Psychiatry 136: 1608–1609, 1979
Barnes RJ, Kong SM, Wu RYY. Electrocardiographic changes in amitriptyline poisoning. British Medical Journal 3: 222–223, 1968
Baum T, Shropshire AT, Rowles G, Gluckman MI. Antidepressants and cardiac conduction: iprindole and imipramine. European Journal of Pharmacology 13: 287–291, 1971
Beaubien AR, Carpenter DC, Mathieu LF, MacConaill M, Hrdina PD. Antagonism of imipramine poisoning by anticonvulsants in the rat. Toxicology and Applied Pharmacology 38: 1–6, 1976
Beighton P, Hardingham M. Amitriptyline poisoning treated by forced diuresis. Practitioner 197: 354–357, 1966
Bessen HA, Niemann JT, Haskell RJ, Rothstein RJ. Effect of respiratory alkalosis in tricyclic antidepressant overdose. Western Journal of Medicine 139: 373–376, 1983
Bickel MH. Poisoning by tricyclic antidepressant drugs. General and pharmacokinetic considerations. International Journal of Clinical Pharmacology 11: 145–176, 1975
Biggs JT, Spiker DG, Petit JM, Ziegler VE. Tricyclic antidepressant overdose: incidence of symptoms. Journal of the American Medical Association 238: 135–138, 1977
Bismuth C, Bodin F, Pebay-Peyroula F, Fréjaville J-P. Intoxication aiguë par l’imipramine avec insuffisance cardiaque aiguë. Presse Medicale 76: 2277–2278, 1968
Bismuth C, Pebay-Peyroula F, Fréjaville J-P, Efthymiou M-L, Fournier E. 245 nouveaux cas d’intoxications aiguë par les dérivés tricycliques. Traitment par les sels de sodium. European Journal of Toxicology 6: 285–291, 1969
Bjaeldager PAL, Hunding A, Nordestgård A, Munck LK, Breum L. Forgiftninger med tricyklise antidepressiva. Indlaeggelser i forgiftningscentralen i 1980. Ugeskrift for Laeger 146: 185–188, 1984
Bland DC, McQuaid A. Successful treatment by haemodialysis of massive overdose of imipramine and sodium Amytal. Clinical Trials Journal 3: 425–427, 1966
Boehnert MT, Lovejoy FH. Value of QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. New England Journal of Medicine 313: 474–479, 1985
Boselli L, Bozza-Marrubini ML, Ghezzi R, Sottili S, Selenati A. Eserine: an antidote of the anticholinergic syndrome. Veterinary and Human Toxicology 21 (Suppl.): 102–104, 1979
Bossaert L, Vermeire P, van Durme JP, Pannier R. Cardiovasculaire afwijkingen bij akute intoxicaties door tricyclische antidepressiva. Acta Clinica Belgica 26: 328–336, 1971
Bouffard Y, Palmier B, Bouletreau P, Motin J. Intoxication aiguë par les antidepresseurs tricycliques. Critères de gravité et traitment. Étude de 16 observations avec manifestations cardio-vasculaires. Annales de Medicine Interne (Paris) 133: 256–260, 1982
Bourin M, Ginies G, Renard JP, Lamisse F, Choutet P, et al. Intoxications aiguës voluntaires par les antidepresseurs tricycliques. Semaine des Hôpitaux de Paris 55: 1501–1505, 1979
Brackenridge RG, Peters TJ, Watson JM. Myocardial damage in amitriptyline and nortriptyline poisoning. Scottish Medical Journal 13: 208–210, 1968
Braithwaite RA, Crome P, Dawling S. The in vitro and in vivo evaluation of activated charcoal as an adsorbent of tricyclic antidepressants. British Journal of Clinical Pharmacology 5: 369P, 1978
Braithwaite RA, Crome P, Dawling S. Amitriptyline overdosage. Plasma concentrations and clinical features. British Journal of Clinical Pharmacology 8: 388P–389P, 1979
Bramble MG, Lishman AH, Purdon J, Diffey BL, Hall RJC. An analysis of plasma levels and 24-hour ECG recordings in tricyclic antidepressant poisoning: implications for management. Quarterly Journal of Medicine 56: 357–366, 1985
Braun L, Broedehl J, Fichsel H, Kallfelz C. Uber imipraminin-toxikation in kindesalter. Medizinische Klinik 60: 1737–1742, 1965
Brown KGE, McMichen HUS, Briggs DS. Tachyarrhythmia in severe imipramine overdose controlled by practolol. Archives of Disease in Childhood 47: 104–106, 1972
Brown TCK. Sodium bicarbonate treatment for tricyclic antidepressant arrhythmias in children. Medical Journal of Australia 2: 380–382, 1976a
Brown TCK. Tricyclic antidepressant overdosage. Experimental studies on the management of circulatory complications. Clinical Toxicology 9: 255–272, 1976b
Brown TCK. Sodium bicarbonate and tricyclic-antidepressant poisoning. Lancet 1: 375, 1977
Brown TCK, Barker GA, Dunlop ME, Loughnan PM. The use of sodium bicarbonate in the treatment of tricyclic antidepressant-induced arrhythmias. Anaesthesia and Intensive Care 1: 203–210, 1973
Brown TCK, Dwyer ME, Stocks JG. Antidepressant overdosage in children — a new menace. Medical Journal of Australia 2: 848–851, 1971
Bryan CK, Ludy JA, Hak SH, Roberts R, Marshall WR. Overdoses with tricyclic antidepressants. Two case reports. Drug Intelligence and Clinical Pharmacy 10: 380–384, 1976
Buckley BM, Boldy DA, Vale JA. The importance of pH and blood gas monitoring after overdoses of tricyclic antidepressants. British Medical Journal 289: 185, 1984
Burks JS, Walker JE, Rumack BH, Ott JE. Tricyclic antidepressant poisoning. Reversal of coma, choreoathetosis and myoclonus by physostigmine. Journal of the American Medical Association 230: 1405–1407, 1974
Burrows GD, Vohra J, Hunt D, Sloman JG, Scoggins BA, Davies B. Cardiac effects of different tricyclic antidepressant drugs. British Journal of Psychiatry 129: 335–341, 1976
Chambers T, Kindley AD. Amitriptyline poisoning in childhood. British Medical Journal 3: 687, 1974
Chin L, Picchioni AL, Bourn WM, Laird HE. Optimal antidotal doses of activated charcoal. Toxicology and Applied Pharmacology 26: 103–108, 1973
Christensen KN, Andersen HH. Deliberate poisoning with tricyclic antidepressants treated in intensive care unit. Acta Pharmacologica et Toxicologica 41 (Suppl. 2): 511–515, 1977
Clemmensen C, Nilsson E. Therapeutic trends: the treatment of barbiturate poisoning. Clinical Pharmacology and Therapeutics 2: 220–229, 1961
Collins J, Goulding R. Pulmonary disease after amitriptyline overdosage. British Medical Journal 2: 300–301, 1973
Connelly JF, Venables AW. A case of poisoning with ‘Tofranil’. Medical Journal of Australia 1: 108, 1961
Cooney DO. Activated charcoal, Marcel Dekker, New York & Basel, 1980
Crome P. Poisoning by tricyclic antidepressant drugs. MD thesis, University of London, 1980
Crome P. Antidepressant overdosage. Drugs 23: 431–461, 1982
Crome P, Adams R, Ali C, Dallos V, Dawling S. Activated charcoal in tricyclic antidepressant poisoning: pilot controlled clinical trial. Human Toxicology 2: 205–209, 1983
Crome P, Braithwaite RA. Relationship between clinical features of tricyclic antidepressant poisoning and plasma concentrations in children. Archives of Disease in Childhood 53: 902–905, 1978
Crome P, Braithwaite RA, Widdop B, Medd RK. Haemoperfusion in clinical and experimental tricyclic antidepressant poisoning. In Sideman & Chang (Eds) Hemoperfusion: kidney and liver support and detoxification, pp. 301–306, Hemisphere Publishing Corporation, Washington, 1980a
Crome P, Dawling S, Braithwaite RA, Masters J, Walkey R. Effect of activated charcoal on absorption of nortriptyline. Lancet 1: 1203–1205, 1977
Crome P, Hampel G, Vale JA, Volans GN, Widdop B, et al. Haemoperfusion in treatment of drug intoxication. British Medical Journal 1: 174, 1978
Crome P, Hampel G, Widdop B, Goulding R. Experience with cellulose acetate coated activated charcoal column haemoperfusion in the treatment of severe drug intoxication. Postgraduate Medical Journal 56: 763–766, 1980b
Crome P, Newman B. Fatal tricyclic antidepressant poisoning. Journal of the Royal Society of Medicine 72: 649–653, 1979a
Crome P, Newman B. The problem of tricyclic antidepressant poisoning. Postgraduate Medical Journal 55: 528–532, 1979b
Crome P, Widdop B. Resin haemoperfusion in tricyclic antidepressant poisoning. Lancet 1: 306–307, 1980
Davies DM, Allaye R. Amitriptyline poisoning. Lancet 2: 543, 1963a
Davies DM, Allaye R. Amitriptyline poisoning. Lancet 2: 643, 1963b
Dawling S, Crome P, Braithwaite R. Effect of delayed administration of activated charcoal on nortriptyline absorption. European Journal of Clinical Pharmacology 14: 445–447, 1978
Dencker H, Dencker SJ, Green A, Nagy A. Intestinal absorption, demethylation and enterohepatic circulation of imipramine. Clinical Pharmacology and Therapeutics 19: 584–586, 1976
Dubuc M, Friborg J, Houde M, Laplante L. Traitement de l’intoxication medicamenteuse aux agents antidepresseurs tricycliques: pour ou contre l’utilisation de la physostigmine. L’Union Medicale du Canada 110: 555–557, 1981
Dumovic P, Burrows GD, Vohra J, Davies B, Scoggins BA. The effect of tricyclic antidepressant drugs on the heart. Archives of Toxicology 35: 255–262, 1976
Duraković Z, Plavšić F, Ivanović D, Gašparović V, Gjurašin M. Resin haemoperfusion in the treatment of tricyclic antidepressant overdose. Artificial Organs 6: 205–207, 1982
Duvoisin RC, Katz R. Reversal of central anticholinergic syndrome in man by physostigmine. Journal of the American Medical Association 206: 1963–1965, 1968
Editorial. Emetics for acute poisoning — treatment or hazard? British Medical Journal 2: 97, 1977
Editorial. Physostigmine for tricyclic antidepressant overdosage. Medical Letter on Drugs and Therapeutics 22: 55, 1980
Edwards AL. Imipramine myocardial toxicity. New York State Journal of Medicine 64: 1979–1982, 1964
Edwards J. Fatal imipramine overdosage. Medical Journal of Australia 1: 839–840, 1966
Fasoli RA, Glauser FL. Cardiac arrhythmias and ECG abnormalities in tricyclic antidepressant overdose. Clinical Toxicology 18: 155–163, 1981
Fendrick GM. Amitriptyline poisoning. New England Journal of Medicine 267: 1031–1032, 1962
Filias N, Jornod J. Les complications cardio-vasculaires des antidépresseurs tricycliques. A propos d’un cas d’intoxication aigue. Revue Medicale de la Suisse Romanade 93: 1005–1012, 1973
Fournier E. Intoxication par les antidépresseurs tricycliques. Therapie 28: 307–320, 1973
Fouron J-C, Chicoine R. ECG changes in fatal imipramine (Tofranil) intoxication. Pediatrics 48: 777–781, 1971
Freeman JW, Loughead MG. Beta blockade in the treatment of tricyclic antidepressant overdosage. Medical Journal of Australia 1: 1233–1235, 1973
Freeman JW, Mundy GR, Beattie RR, Ryan C. Cardiac abnormalities in poisoning with tricyclic antidepressants. British Medical Journal 2: 610–611, 1969
Frei A, Ritz R. Intensivuberwachung bei intoxikation mit trizklischen antidepressiva? Schweitzerische Medizinische Wochenschrift 113: 1138–1140, 1983
Fréjaville JP, Efthymiou ML, Mellerio F, Fournier E, Gervaise P, et al. Cent cas d’intoxication aiguë par les dérivés de l’iminodibenzyl (imipramine, amitryptiline et trimépyramine). Bulletin de la Societe Medicale des Hôpitaux de Paris 116: 927–945, 1965
Fréjaville JP, Nicaise AM, Christoforov B, Sraer JD, Pebay-Peyroula F, et al. Etude statistique d’une seconde centaine d’intoxications aigues par les dérivés de l’iminodibenzyle (Tofranil, Pertofran, G 34, Surmontil) et ceux du dihydrobenzocycloheptadiène (Laroxyl, Elavil). Bulletin de la Société Médicale des Hôpitaux de Paris 117: 1151–1175, 1966
Gard H, Knapp D, Walle T, Gaffey T, Hanenson I. Qualitative and quantitative studies on the disposition of amitriptyline and other tricyclic antidepressants in man as it relates to the management of the overdosed patient. Clinical Toxicology 6: 571–584, 1973
Garrison HF, Moffitt EM. Imipramine hydrochloride intoxication. Journal of the American Medical Association 179: 456–458, 1962
Gaultier M. Sodium bicarbonate and tricyclic-antidepressant poisoning. Lancet 2: 1258, 1976
Gaultier M, Boissier JR, Gorceix A, Simon P. The cardiotoxicity of imipramine in man and animals. Proceedings of the European Society for the Study of Drug Toxicity 6: 171–178, 1965
Gibb SM, Unsworth RW, Ilett KF. Ipecacuahna as an emetic for adults. British Medical Journal 2: 1474–1475, 1977
Giles HMC. Imipramine poisoning in childhood. British Medical Journal 2: 844–846, 1963
Goel KM, Shanks RA. Amitriptyline and imipramine poisoning in children. British Medical Journal 1: 261–263, 1974
Goulding R, Volans GN. Emergency treatment of common poisons: emptying the stomach. Proceedings of the Royal Society of Medicine 70: 766–770, 1977
Greenblatt DJ, Koch-Weser J, Shader RI. Multiple complications and death following protriptyline overdose. Journal of the American Medical Association 229: 556–557, 1974
Greenland P, Howe TA. Cardiac monitoring in tricyclic anti-depressant overdose. Heart and Lung 10: 856–859, 1981
Halle MA, Collipp PJ. Amitriptyline hydrochloride poisoning: unsuccessful treatment by peritoneal dialysis. New York State Journal of Medicine 69: 1434–1436, 1969
Hallstrom C, Gifford L. Antidepressant blood levels in acute overdose. Postgraduate Medical Journal 52: 687–688, 1976
Hampel G, Crome P, Widdop B, Goulding R. Experience with fixed-bed charcoal haemoperfusion in the treatment of severe drug intoxication. Archives of Toxicology 45: 131–141, 1980
Harthorn JW, Marcus AM, Kaye M. Management of massive imipramine overdosage with mannitol and artificial dialysis. New England Journal of Medicine 268: 33–36, 1968
Hayden JW, Comstock EG. Use of activated charcoal in acute poisoning. Clinical Toxicology 8: 513–533, 1975
Heath A, Wickstrom I, Ahlmen J. Haemoperfusion in tricyclic antidepressant poisoning. Lancet 1: 155, 1980
Heath A, Wickstrom I, Martensson E, Ahlem J. Treatment of antidepressant poisoning with resin haemoperfusion. Human Toxicology 1: 361–371, 1982
Heiser JF, Wilbert DE. Reversal of delirium induced by tricyclic antidepressant drugs with physostigmine. American Journal of Psychiatry 131: 1275–1277, 1974
Henry J, Volans G. ABC of poisoning. I. Drugs. British Medical Journal, London, 1984
Hodes D. Sodium bicarbonate and hyperventilation in treating an infant with severe overdose of tricyclic antidepressant. British Medical Journal 288: 1800–1801, 1984
Hoffman JR, McElroy CR. Bicarbonate therapy for dysrhythmia and hypotension in tricyclic antidepressant overdose. Western Journal of Medicine 134: 60–64, 1981
Holinger PC, Klawans HL. Reversal of tricyclic overdosage-induced central anticholinergic syndrome by physostigmine. American Journal of Psychiatry 133: 1018–1023, 1976
Holt LE, Holz PH. The black bottle. Journal of Pediatrics 63: 306–314, 1963
Hong WK, Mauer P, Hochman R, Casiowitz JG, Paraskos JA. Amitriptyline cardiotoxicity. Chest 66: 304–306, 1974
Hulten BA, Heath A. Clinical aspects of tricyclic antidepressant poisoning. Acta Medica Scandinavica 213: 275–278, 1983
Iversen BM, Willassen M, Bakke OM. Charcoal haemoperfusion in nortriptyline poisoning. Lancet 1: 388–389, 1978
Janson PA, Watt JB, Hermos JA. Doxepin overdose. Success with physostigmine and failure with neostigmine in reversing toxicity. Journal of the American Medical Association 237: 2632–2633, 1977
Jeong Y-G, Caccamo LP. Amitriptyline poisoning causing left bundle branch block. Ohio State Medical Journal 72: 217–219, 1976
Johnson PB. Physostigmine in tricyclic antidepressant overdose. Journal of the American College of Emergency Physicians 5: 443–445, 1976
Kanarek KS, Thomson PD, Levin SE. The management of imipramine (Tofranil) intoxication in children. South African Medical Journal 47: 835–838, 1973
Kergall C. L’étude de 36 cas d’intoxications massive par l’imipramine. Presse Medicale 72: 2452, 1964
Kuhn R. Uber die behandlung depressiver zustaende mit einem iminodibenzylderivat (G22355). Schweitzerische Medizinische Wochenschrift 87: 1135–1140, 1957
Kuhn WF, Jones DR, Lippmann SB, Embry CK, Williams WM, et al. Clinical and pharmacological considerations in elimination of tricyclic antidepressant and metabolites after overdose. Journal of Clinical Psychopharmacology 4: 158–160, 1984
Laddu AR, Somani P. Desipramine toxicity and its treatment. Toxicology and Applied Pharmacology 15: 287–294, 1969
Lancaster NP, Foster AR. Suicidal attempt by imipramine overdosage. British Medical Journal 1: 338–389, 1959
Langou RA, van Dyke C, Tahan SR, Cohen LS. Cardiovascular manifestations of tricyclic antidepressant overdose. American Heart Journal 100: 458–464, 1980
Lee FI. Imipramine overdosage — report of a fatal case. British Medical Journal 1: 338–339, 1961
Lloyd TW, Hart DR. Amitriptyline poisoning. Lancet 2: 544, 1965
Lomholt BS. Hyperventilationsbehandling ved akut forgiftning med tricykliske antidepressiva. Ugeskrift for Laeger 138: 4–9, 1976
Mann R. Discussion. Canadian Psychiatric Association Journal 4: S66–S67, 1959
Marshall A, Moore K. Pulmonary disease after amitriptyline overdosage. British Medical Journal 1: 716–717, 1973
Marshall JB. Tricyclic overdose. Journal of the American Medical Association 244: 1900, 1980
Marshall JB, Forker AD. Tricyclic antidepressant overdose: clinical and cardiovascular features. Nebraska Medical Journal 65: 77–80, 1980
Marshall JB, Forker AD. Cardiovascular effects of tricyclic antidepressant drugs: therapeutic usage, overdose and management of complications. American Heart Journal 103: 401–414, 1982
Masters AB. Delayed death in imipramine poisoning. British Medical Journal 2: 866–867, 1967
Mathew H, Lawson AA. Treatment of acute poisoning, Churchill, New York, 1969
Meredith TJ, Vale JA. Poisoning due to psychotropic agents. Adverse Drug Reactions and Acute Poisoning Reviews 4: 83–126, 1985
Michon P, Larcan A, Huriet C, Beaudouin D, Berthier X. Intoxication volontaire mortelle par imipramine (G22-355). Bulletin de la Societe Medicale des Hôpitaux de Paris 4: 989–992, 1959
Munoz RA. Treatment of tricyclic intoxication. American Journal of Psychiatry 133: 1085–1087, 1976
Nattel S, Bayne L, Ruedy J. Physostigmine in coma due to drug overdose. Clinical Pharmacology and Therapeutics 25: 96–102, 1979
Newton RW. Physostigmine salicylate in the treatment of tricyclic antidepressant overdosage. Journal of the American Medical Association 231: 941–943, 1975
Nicotra MB, Rivera M, Pool JL, Noall MW. Tricyclic antidepressant overdose: clinical and pharmacologic observations. Clinical Toxicology 18: 599–613, 1981
Noble J, Matthew H. Acute poisoning by tricyclic antidepressants. Clinical features and management of 100 patients. Clinical Toxicology 2: 403–421, 1969
Nogue Xarau S, Nadal Trias P, Bertran Georges A, Mas Ordeig A, Munne Mas P, et al. Intoxication aguda grave por antidepresivos triciclicos. Estudio retrospectivo de 15 casos. Medicina Clinica 74: 257–262, 1980
Noto R, Robert J, Hanote P. Traitement d’urgence et transport des intoxications aiguës par les dérivés imipraminiques. Agressologie 11: 515–524, 1970
O’Keefe DB, Crome P, Medd RK. The effects of physostigmine on amitriptyline induced cardiotoxicity in dogs. Veterinary and Human Toxicology 21 (Suppl.): 58–60, 1979
Openheim RC, Stewart NF. Adsorption of tricyclic antidepressants by activated charcoal. I. Adsorption in low pH conditions. Australian Journal of Pharmaceutical Sciences NS4: 79–84, 1975
Orr DA, Bramble MG. Tricyclic antidepressant poisoning and prolonged external massage during asystole. British Medical Journal 283: 1107–1108, 1981
Pall H, Czech K, Kotzaurek R, Kleinberger G, Pichler M. Experiences with physostigmine salicylate in tricyclic antidepressant poisoning. Acta Pharmacologica et Toxicologica 41 (Suppl. 2): 171–178, 1977
Park J, Proudfoot AT. Acute poisoning with maprotiline hydrochloride. British Medical Journal 1: 1573, 1977
Pearson JD, Jones ES, Gabbe DM. Cardiac arrest and arrhythmia due to self-poisoning with imipramine. Anaesthesia 24: 69–71, 1969
Pebay-Peyroula F, Bismuth C, Autret A. Premier cas Francais d’intoxication aigué par la doxépine. European Journal of Toxicology 2: 77–78, 1969
Pebay-Peyroula F, Bismuth C, Fréjaville J-P. Toxicité cardiaque de l’imipramine et des imipraminiques. Coeur et Medicine Interne 7: 209–219, 1968
Pedersen OL, Gram LF, Kristensen CB, Moller M, Thayssen P, et al. Overdosage of antidepressants: clinical and pharmacokinetic aspects. European Journal of Clinical Pharmacology 23: 513–521, 1982
Pedersen RS. Haemoperfusion in tricyclic antidepressant poisoning. Lancet 1: 154–155, 1980
Pedersen RS, Jorgansen KA, Olsen AS, Christensen KN. Charcoal haemoperfusion for antidepressant overdose. Lancet 1: 179, 1978
Pentel P, Benowitz. Tricyclic antidepressant poisoning: management of arrhythmias. Medical Toxicology 1: 101–121, 1986
Pentel P, Bullock ML, De Vane CL. Haemoperfusion for imipramine overdoses: elimination of active metabolites. Journal of Toxicology, Clinical Toxicology 19: 239–248, 1982
Pentel P, Peterson CD. Asystole complicating physostigmine treatment of tricyclic antidepressant overdose. Annals of Emergency Medicine 9: 588–590, 1980
Pentel P, Sioris L. Incidence of late arrhythmias following tricyclic antidepressant overdose. Clinical Toxicology 18: 543–548, 1981
Perel A, Cotev S. Imipramine (Tofranil) intoxication. A case report and review of management. Critical Care Medicine 4: 274–276, 1976
Petit JM, Spiker DG, Biggs JT. Psychiatric diagnosis and tricyclic plasma levels in 36 hospitalized overdose patients. Journal of Nervous and Mental Disease 163: 289–293, 1976a
Petit JM, Spiker DG, Ruwitch JF, Ziegler VE, Weiss AN, et al. Tricyclic antidepressant plasma levels and adverse effects after overdosage. Clinical Pharmacology and Therapeutics 21: 47–51, 1976b
Pinder RM, Brogden RN, Speight TM, Avery GS. Maprotiline: a review of its pharmacological properties and therapeutic efficacy in mental depressive states. Drugs 13: 321–352, 1977
Postelthwaite RJ, Price DA. Amitriptyline and imipramine poisoning in children. British Medical Journal 2: 504, 1974
Price DA, Postelthwaite RJ. Amitriptyline and imipramine poisoning in children. British Medical Journal 1: 575, 1974
Proudfoot AT. Diagnosis and management of acute poisoning, Blackwell Scientific Publications, Oxford, 1982
Proudfoot AT, Park J. Changing pattern of drugs used for self-poisoning. British Medical Journal 1: 90–93, 1978
Prout BJ, Young J, Goddard P. Imipramine poisoning in childhood and suggested treatment. British Medical Journal 1: 972, 1965
Prudhommeaux J-L, Lechat P, Auclair MC. Etude expérimentale de l’influence des ions sodium sur la toxicité cardiaque de l’imipramine. Therapie 23: 675–683, 1968
Ramsay ID. Survival after imipramine poisoning. Lancet 2: 1308–1309, 1967
Rasmussen J. Amitriptyline and imipramine poisoning. Lancet 2: 850–851, 1965
Rendoing J, Choisy H, Pascalis G, Bajolet A, Gisselmann A. Intoxication aiguë par la nortriptyline. Presse Medicale 77: 439–440, 1969
Roberts RJ, Mueller S, Lauer RM. Propranolol in the treatment of cardiac arrhythmias associated with amitriptyline intoxication. Journal of Pediatrics 82: 65–67, 1973
Rosen MJ. Tricyclic antidepressant overdose: clinical features and management. Heart and Lung 12: 222–225, 1983
Rudorfer MV, Robins E. Fatal nortriptyline overdose, plasma levels, and in vivo methylation of tricyclic antidepressants. American Journal of Psychiatry 138: 982–983, 1981
Rumack BH. Physostigmine: rational use. Journal of the American College of Emergency Physicians 5: 541–542, 1976
Rushnak MJ, McGovern DP. Reversal of imipramine cardiotoxicity with physostigmine. Journal of the Medical Society of New Jersey 74: 155–157, 1977
Sabet LM. Bilateral symmetrical brain lesions in tricyclic antidepressant overdosage. Canadian Journal of Neurological Sciences 7: 305–307, 1980
Sacks MH, Bonforte RJ, Lasser RP, Dimich I. Cardiovascular complications of imipramine intoxication. Journal of the American Medical Association 205: 588–590, 1968
Sedal L, Korman MG, Williams PO, Mushin G. Overdosage of tricyclic antidepressants: a report of two deaths and a prospective study of 24 patients. Medical Journal of Australia 2: 74–79, 1972
Seitz R, Wehr M, Pallmert N. Arrhythmien bei Vergiftung durch trizyklische antidepressiva. Erfolgreiche behandlung mit physostigmin und natrium. Deutsche Medizinische Wochenschrift 107: 1096–1099, 1982
Serafimovski N, Thorball N, Asmussen I, Lunding M. Tricyclic antidepressant poisoning with special reference to cardiac complications. Acta Anaesthesiologica Scandinavica Suppl. 57: 55–63, 1975
Sesso AM, Snyder RC, Schott CE. Propranolol in imipramine poisoning. American Journal of Diseases of Children 126: 847–849, 1973
Sharman JR, Cretney MJ, Scott RD, Janus ED. Drug overdoses: is one stomach washing enough? New Zealand Medical Journal 81: 195–197, 1975
Siddiqui JH, Vakassi MM, Ghani MF. Cardiac effects of amitriptyline overdosage. Current Therapeutic Research 22: 321–325, 1977
Sigg EB. Pharmacological studies with Tofranil. Canadian Psychiatric Association Journal 4: S75–S85, 1959
Sigg EB, Osborne M, Korol B. Cardiovascular effects of imipramine. Journal of Pharmacology and Experimental Therapeutics 141: 237–243, 1963
Singh BN, Hauswirth O. Comparative mechanisms of action of antiarrhythmic drugs. American Heart Journal 87: 367–382, 1974
Slovis TL, Ott JE, Teitelbaum DT, Lipscomb W. Physostigmine therapy in acute tricyclic antidepressant poisoning. Clinical Toxicology 4: 451–459, 1971
Snyder BD, Blonde L, McWhirter WR. Reversal of amitriptyline intoxication by physostigmine. Journal of the American Medical Association 230: 1433–1434, 1974
Southall DP, Kilpatrick SM. Imipramine poisoning: survival of a child after prolonged cardiac massage. British Medical Journal 4: 508, 1974
Spiker DG, Biggs JT. Tricyclic antidepressants: prolonged plasma levels after overdose. Journal of the American Medical Association 236: 1711–1712, 1976
Spiker DG, Weiss AN, Chang SS, Ruwitch JF, Biggs JT. Tricyclic antidepressant overdosage: clinical presentation and plasma levels. Clinical Pharmacology and Therapeutics 18: 539–546, 1975
Stannard M, Caplan HL. Cardiac arrest due to imipramine hydrochloride. Medical Journal of Australia 2: 22–24, 1967
Starkey IR, Lawson AAH. Poisoning with tricyclic and related antidepressants: a ten-year review. Quarterly Journal of Medicine 49: 33–49, 1980a
Starkey IR, Lawson AAH. Psychiatric aspects of acute poisoning with tricyclic and related antidepressants: a ten year review. Scottish Medical Journal 25: 303–308, 1980b
Stinnett JL, Valentine J, Abrutyn E. Nortriptyline hydrochloride overdosage. Journal of the American Medical Association 204: 167–169, 1968
Strøm J, Sloth Madsen P, Nygaard Nielsen N, Bredgaard Sørensen M. Acute self-poisoning with tricyclic antidepressants in 295 consecutive patients treated in an ICU. Acta Anaesthesiologica Scandinavica 28: 666–670, 1984
Sueblinvong V, Wilson JF. Myocardial damage due to imipramine intoxication. Journal of Pediatrics 74: 475–478, 1969
Sunshine P, Yaffe SJ. Amitriptyline poisoning. American Journal of Diseases in Children 106: 501–506, 1963
Sutherland GR, Park J, Proudfoot AT. Ventilation and acid-base changes in deep coma due to barbiturate or tricyclic antidepressant poisoning. Clinical Toxicology 11: 403–412, 1977
Swartz CM, Sherman A. The treatment of tricyclic antidepressant overdose with repeated charcoal. Journal of Clinical Psycho-pharmacology 4: 336–340, 1984
Thorstrand C. Cardiovascular effects of poisoning with tricyclic antidepressants. Acta Medica Scandinavica 195: 505–514, 1974
Thorstrand C. Clinical features in poisonings by tricyclic antidepressants with special reference to the ECG. Acta Medica Scandinavica 199: 337–344, 1976
Thorstrand C. Haemodynamic effects following toxic doses of tricyclic antidepressants. Acta Pharmacologica et Toxicologica 41 (Suppl. 2): 48, 1977
Tobis J, Das BN. Cardiac complications in amitriptyline poisoning: successful treatment with physostigmine. Journal of the American Medical Association 235: 1474–1476, 1976
Trafford JAP, Jones RH, Evans R, Sharp P, Sharpstone P, et al. Haemoperfusion with R-004 amberlite resin for treating acute poisoning. British Medical Journal 2: 1453–1456, 1977
Trafford A, Sharpstone P, O’Neal H. Haemoperfusion in tricyclic antidepressant poisoning. Lancet 1: 155, 1980
Vale JA, Meredith TJ. A concise guide to the management of poisoning, Churchill Livingstone, Edinburgh, 1985
Vaughan Williams EM. Electrophysiological basis for a rational approach to antidysrhythmic therapy. Advances in Drug Research 9: 69–101, 1974
Vohra J, Burrows G, Hunt D, Sloman G. The effect of toxic and therapeutic doses of tricyclic antidepressant drugs on intracardiac conduction. European Journal of Cardiology 3: 219–227, 1975a
Vohra JK, Hunt D, Burrows G, Sloman G. Intracardiac conduction defects following overdose of tricyclic antidepressant drugs. European Journal of Cardiology 2: 453–458, 1975b
Williams AJ. Desipramine overdosage. British Medical Journal 1: 371–372, 1964
Williams RB, Sherter C. Cardiac complications of tricyclic antidepressant therapy. Annals of Internal Medicine 74: 395–398, 1971
Woodhead R. Cardiac rhythm in tricyclic antidepressant poisoning. Clinical Toxicology 14: 499–505, 1979
Wright SP. Usefulness of physostigmine in imipramine poisoning. Clinical Pediatrics 15: 1123–1128, 1976
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Crome, P. Poisoning Due to Tricyclic Antidepressant Overdosage. Medical Toxicology 1, 261–285 (1986). https://doi.org/10.1007/BF03259843
Published:
Issue Date:
DOI: https://doi.org/10.1007/BF03259843