July 3, 2009

Antidepressant Overdose and Episode 86

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Welcome to Episode 86

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News–

Australian Chief Nurse Proclaimed ICN President

Community Nursing Restructured in Scotland

FDA votes to Eliminate Combination Drugs

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Tip of the Week– Antidepressant Overdose with Lisa Booze of the Maryland Poison Center

According to the World Health Organization, depression affects about 121 million people worldwide and is a leading cause of disability. This is why antidepressants are widely used especially in the US. Symptoms of depression manifested are not the same for different individuals so the type of antidepressant and dose to be taken should be chosen with caution.

The different classifications of antidepressants are:

Selective Serotonin Reuptake Inhibitors (SSRI)
- eg. Prozac (fluoxetine), Paxil (paroxetine)

Serotonin and Norepinephrine Reuptake Inhibitors (SSNIs)
- eg. )Effexor (venlafaxine), Cymbalta (duloxetine)

Tricyclic antidepressants (TCAs)
- eg. Elavil (amitriptyline), Tofranil (imipramine)

Monoamine Oxidase Inhibitors (MAOIs)
- eg. Nardil (phenelzine), Parnate (tranylcypromine)

SSRI’s are regarded as first-line therapy for depression but TCAs remain to be widely used not only for depression but also for other conditions like anxiety disorders, ADD, pediatric enuresis and chronic pain disorders. Overdose from TCAs are among the most common causes of drug poisoning seen in emergency departments.

Tricyclics are identified as one of the most frequently ingested substances in poisoning along with paracetamol, benzodiazepines and alcohol. They are second to analgesics as most common drug taken in fatal drug overdose.

The clinical features of antidepressant overdose include the following:

CNS

altered mental status, delirium, psychotic behavior, delirium and hallucinations and later proceeds to lethargy, stupor, and coma.
generalized seizures within 1-2 hours of ingestion
pyramidal signs
rigidity

Cardiovascular

Hypotension
Dysrhythmias
Conduction block
Slowed ventricular conduction
Sinus Tachycardia
Hypertension (early)
Cardiogenic shock

Respiratory

Acute lung injury
Hypoventilation
Aspiration pneumonitis
ARDS
Hypoxia

Anticholinergic effects

Hypothermia
Agitation (early)
Mydriasis
Dry skin and/or mucous membranes
Hyperthermia
Decreased gastric motility/ileus
Urinary retention

Management of antidepressant overdose includes measures to reduce absorption, alkalinisation, providing anti-arrhythmic treatment, management of hypotension and convulsions. Patients should also be closely monitored for risk of cardiac arrest and seizure precautions should be instituted.

Emergency Medicine Journal Review on Tricyclic Antidepressant Overdose

Understanding Antidepressant Medications

Article on Antidepressant Toxicity