Monitoring Stable patients in Tricyclic antidepressant overdose
Date First Published:
July 11, 2005
Last Updated:
July 13, 2005
Report by:
Fawad Azam, Medical Student (MRI)
Three-Part Question:
In [Tricyclic antidepressant overdose] how long [must a clinically stable patient be monitored] before they can be [safely discharged]
Clinical Scenario:
A 29 year old woman presents to the emergency department with tricyclic antidepressant overdose. She remains alert and shows no sign of major toxicity. You wonder how long this patient must be monitored before she can be safely discharged
Search Strategy:
MEDLINE 1966-June Week 4 2005 OVID Interface
EMBASE 1980 to 2005 Week 27 OVID Interface
EMBASE 1980 to 2005 Week 27 OVID Interface
Search Details:
Medline:[{exp ANTIDEPRESSIVE AGENTS, TRICYCLIC OR tricyclic.mp. OR amitriptyline.mp. OR exp AMITRIPTYLINE OR desipramine.mp. OR exp DESIPRAMINE OR clomipramine.mp. OR exp CLOMIPRAMINE OR doxepin.mp. OR exp DOXEPIN OR dothiepin.mp. OR exp DOTHIEPIN OR imipramine.mp. OR exp IMIPRAMINE OR lofepramine.mp. OR exp LOFEPRAMINE OR nortriptyline.mp. OR exp NORTRIPTYLINE OR trimipramine.mp. OR exp TRIMIPRAMINE} AND {overdose.mp. OR exp OVERDOSE OR exp POISONING} AND {monitoring.mp. OR exp MONITORING, PHYSIOLOGIC OR exp PATIENT ADMISSION OR admission.mp. OR exp Hospitalization OR admit.mp} LIMIT to English language AND Humans]
Embase: [{exp ANTIDEPRESSIVE AGENTS, TRICYCLIC OR tricyclic.mp. OR amitriptyline.mp. OR exp AMITRIPTYLINE OR desipramine.mp. OR exp DESIPRAMINE OR clomipramine.mp. OR exp CLOMIPRAMINE OR doxepin.mp. OR exp DOXEPIN OR dothiepin.mp. OR exp DOTHIEPIN OR imipramine.mp. OR exp IMIPRAMINE OR lofepramine.mp. OR exp LOFEPRAMINE OR nortriptyline.mp. OR exp NORTRIPTYLINE OR trimipramine.mp. OR exp TRIMIPRAMINE} AND {overdose.mp. OR exp OVERDOSE OR exp POISONING} AND {monitoring.mp. OR exp MONITORING, PHYSIOLOGIC OR exp PATIENT ADMISSION OR admission.mp. OR exp Hospitalization OR admit.mp} LIMIT to English language AND Humans]
Embase: [{exp ANTIDEPRESSIVE AGENTS, TRICYCLIC OR tricyclic.mp. OR amitriptyline.mp. OR exp AMITRIPTYLINE OR desipramine.mp. OR exp DESIPRAMINE OR clomipramine.mp. OR exp CLOMIPRAMINE OR doxepin.mp. OR exp DOXEPIN OR dothiepin.mp. OR exp DOTHIEPIN OR imipramine.mp. OR exp IMIPRAMINE OR lofepramine.mp. OR exp LOFEPRAMINE OR nortriptyline.mp. OR exp NORTRIPTYLINE OR trimipramine.mp. OR exp TRIMIPRAMINE} AND {overdose.mp. OR exp OVERDOSE OR exp POISONING} AND {monitoring.mp. OR exp MONITORING, PHYSIOLOGIC OR exp PATIENT ADMISSION OR admission.mp. OR exp Hospitalization OR admit.mp} LIMIT to English language AND Humans]
Outcome:
Medline: 135 studies found of which 5 were relevant to the 3 part question
Embase: 339 studies found of which 2 additional papers were found
Embase: 339 studies found of which 2 additional papers were found
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Criteria for admitting patients with tricyclic antidepressant overdose Tokarski GF. Young MJ 1988 USA | Reviewed 45 TCA overdose patients from 1982-1985 and applied algorithm | Retrospective Cohort Study | Patient discharged using Algorithm (No major signs toxicity/QRS<0.10 in 6hrs) | 20 patient would have been discharged since no signs of major toxicity or QRS was <0.10s within 6 hours of admission. None of these patients developed any complications | small sample retrospective study hence vital data from notes may be missing |
| antidepressant overdose: conservative management in the community hospital with cost saving implications Banahan B, Schelkun P 1990 USA | Reviewed 33 patients with an admission diagnosis of TCA overdose between January 1985-December 1988. Applied algorithm by Tokarski and Young (see below) |
Retrospective Cohort Study | Patients discharged under Algorithm (by Tokarski et al. See above) | 11 patients did not show signs of Major toxicity or QRS>0.10s within 6 hours. Using the Algorithm these patient could been discharged. None developed any complications | small sample retrospective study, hence data may be missing |
| A Predicting severity of tricyclic antidepressant overdose Hulten BA. Adams R. Askenasi R. Dallos V. Dawling S. Volans G Jun-92 Sweden | 67 TCA overdose Patients | Cohort study | Development of Complications | All patients who developed complications did so within 6 hours of admission | Lack of raw data no sample size estimation performed |
| Incidence of Late arrythmias following tricyclic antidepressant overdose Pentel Paul, Sioris Leo 1981 USA | Patients with TCA overdose All underwent Gastric emptying |
Retrospective Cohort Study | Development of Complication | All patients who developed complications did so within 1 hour of hospitalisation. No patients developed arryhthmias after being alert and having a normal ECG for 1 hour. | Does not mention the exact number of patients in the study Vital data may be missing from notes due to retrospective study. |
| Level of consciousness as a predictpr of the complications following tricyclic overdose Emerman C, Connors AF, Burma GM 1987 USA | 92 patients with TCA overdose admission from 1975-85 | Retrospective Cohort Study | Development of complications (26/37 patients had documentation) | 19/26 developed complications within 30 mins. 7/26 developed complications between 30-120 mins. | Data may be missing due to retrospective study |
| cardiac monitoring in tricyclic antidepressant overdose Greenland P, Howe TA 1981 USA | 62 patients with TCA overdose | Retrospective Cohort Study | Cardiac arrhythmias | No cardiac arrhythmias occurred after the first 24 hrs in any patient free of such complication earlier | Lack of raw data important details may be missing in retrospective study |
| Cardiac Complications following tricyclic antidepressant overdose Goldberg RJ, Capone RJ, Hunt JD 1985 USa | 75 patients with TCA overdose | Retrospective Cohort Study | Cardiac complications | No new complications after 24 hrs | Data may be missing due to retrospective study No actual data on times of complications following overdose |
Author Commentary:
Banahan B et al showed in their retrospective study that discharging stable patients with QRS duration< 0.10 seconds for 6 hours could have saved $14,000.
Incidence of late arryhthmias have been reported, however these patients were not absent of clinical signs and in some patients certain clinical procedures were not performed
Incidence of late arryhthmias have been reported, however these patients were not absent of clinical signs and in some patients certain clinical procedures were not performed
Bottom Line:
Stable patients with tricyclic antidepressant overdose who show no sign of toxicity and no significant ECG abnormalities (ie QRS<0.10s) for 6 hours can safely be discharged.
References:
- Tokarski GF. Young MJ. Criteria for admitting patients with tricyclic antidepressant overdose
- Banahan B, Schelkun P. antidepressant overdose: conservative management in the community hospital with cost saving implications
- Hulten BA. Adams R. Askenasi R. Dallos V. Dawling S. Volans G. A Predicting severity of tricyclic antidepressant overdose
- Pentel Paul, Sioris Leo. Incidence of Late arrythmias following tricyclic antidepressant overdose
- Emerman C, Connors AF, Burma GM. Level of consciousness as a predictpr of the complications following tricyclic overdose
- Greenland P, Howe TA. cardiac monitoring in tricyclic antidepressant overdose
- Goldberg RJ, Capone RJ, Hunt JD. Cardiac Complications following tricyclic antidepressant overdose