{"id":4339,"date":"2012-01-03T15:15:49","date_gmt":"2012-01-03T20:15:49","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/im-residency\/?p=4339"},"modified":"2012-01-03T15:15:49","modified_gmt":"2012-01-03T20:15:49","slug":"how-to-recognize-tca-toxicity","status":"publish","type":"post","link":"https:\/\/www.bumc.bu.edu\/im-residency\/2012\/01\/03\/how-to-recognize-tca-toxicity\/","title":{"rendered":"How to recognize TCA toxicity"},"content":{"rendered":"<p>We learnt how to recognize TCA toxicity via discussion of a case of a 54 yo F who was brought in unresponsive\u00a0by EMS after her son called 911. She had a PMH of HCV, prior opioid abuse, depression who was on several medications including toprol, lisinopril, ASA, chlorthalidone, celexa, buspirone, mirtazipine, amitryptiline, MS Contin, klonipin and oxycodone.<\/p>\n<p>On exam she was found to be hypertensive at 205\/110 with sinus tachycardia at 130s breathing at 15. She was noted to be very flushed, warm\/dry skin, pupils 4mm minimally reactive with no focal neurological findings.<\/p>\n<p>Her <a href=\"\/im-residency\/files\/2012\/01\/EKG.ppt\">EKG<\/a> was noted to be have a <strong>triad\u00a0<\/strong>which should raise suspicion of TCA toxicity\u00a0consisting<strong>\u00a0<\/strong>of the following:<\/p>\n<ol>\n<li>prolonged QTc<\/li>\n<li>prolonged QRS (interventricular conduction delay) (due to blockade of fast Na channels in conduction system)<\/li>\n<li>sinus tachycardia (due to vagolytic effect)\u00a0This triad should raise suspicion of TCA cardiac toxicity<\/li>\n<\/ol>\n<p>A specific finding also seen in TCA toxicity is a large (&gt;3mm) <strong>R<\/strong> wave in av<strong>R <\/strong>(which this patient did not have).<\/p>\n<p>Treatment: If QRS is prolonged (&gt;120) then patient should receive IV pushed of hypertonic NaHC03 followed by bicarb gtt (3 amps in 1L D5W @250cc\/hr) and QRS is to be monitored alongwith a goal pH of 7.5-7.55. This molecule is lipophilic and thus\u00a0non-dialyzable. To also contact poison control for assisstance.<\/p>\n<p>Reference articles: <a href=\"http:\/\/www.ncbi.nlm.nih.gov.ezproxy.bu.edu\/pubmed?term=Guidelines%20in%20Emergency%20Medicine%20Network%20(GEMNet)%3A%20guideline%20for%20the%20management%20of%20tricyclic%20antidepressant%20overdose%20Richard%20Body%2C%20Tom%20Bartram%2C%20Fawad%20Azam%2C%20Kevin%20Mackway-Jones\">Guidelines for management of TCA toxicity<\/a>; <a href=\"http:\/\/www.ncbi.nlm.nih.gov.ezproxy.bu.edu\/pubmed?term=Electrocardiographic%20Criteria%20for%20Tricyclic%20Antidepressant%20Cardiotoxicity%20JAMES%20T.%20NIEMANN%2C%20MD%2C%20HOWARD%20A.%20BESSEN%2C%20MD%2C%20ROBERT%20J.%20ROTHSTEIN%2C%20MD%2C%20and%20MICHAEL%20M.%20LAKS%2C%20MD\">EKG manifestations of TCA cardiac toxicity<\/a>; <a href=\"http:\/\/www.ncbi.nlm.nih.gov.ezproxy.bu.edu\/pubmed?term=ECG%20Lead%20aVR%20Versus%20QRS%20Interval%20in%20Predicting%20Seizures%20and%20Arrhythmias%20in%20Acute%20Tricyclic%20Antidepressant%20Toxicity\">aVR in TCA toxicity<\/a>;<\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>\u00a0<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>We learnt how to recognize TCA toxicity via discussion of a case of a 54 yo F who was brought in unresponsive\u00a0by EMS after her son called 911. She had a PMH of HCV, prior opioid abuse, depression who was on several medications including toprol, lisinopril, ASA, chlorthalidone, celexa, buspirone, mirtazipine, amitryptiline, MS Contin, klonipin [&hellip;]<\/p>\n","protected":false},"author":5942,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[4854],"tags":[17628,17634,17627],"_links":{"self":[{"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/posts\/4339"}],"collection":[{"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/users\/5942"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/comments?post=4339"}],"version-history":[{"count":0,"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/posts\/4339\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/media?parent=4339"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/categories?post=4339"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/im-residency\/wp-json\/wp\/v2\/tags?post=4339"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}