Approach to the Critical Patient

Immediate threats

Airway and respiratory priorities

Cardiovascular collapse threats

Seizure threat

Monitoring and targets

Continuous monitoring bundle

pH and sodium monitoring during bicarbonate therapy

Immediate interventions

Resuscitation priorities

GI decontamination

Consult triggers

Immediate consultation requirements

History

Ingestion details

TCA agent identification

Symptom timeline

Presenting symptoms

Vomiting history

Exposure context

Intentional vs accidental

Co-ingestants

Past medical and psychiatric history

Psychiatric history

Medical history

Physical Exam

Vitals and general appearance

Hemodynamic snapshot

Anticholinergic toxidrome findings

Classic anticholinergic signs

Neurological exam

Level of consciousness

Motor exam

Abdominal exam

GI findings

PITFALLS

Diagnostic pitfalls

Differential Diagnosis

Life-threatening mimics

Other sodium channel blocker toxicity

Other cardiotoxic poisonings

Toxidromes that overlap

Anticholinergic toxidrome from other agents

Serotonin syndrome

Cardiac conditions

Primary ventricular arrhythmia

Laboratory Tests

Core toxicology labs

Urine drug screen

Co-ingestant screen

Metabolic and electrolyte panel

Basic metabolic panel

Acid-base and perfusion

Arterial blood gas

Serum lactate

Venous blood gas for serial monitoring

Cardiac biomarkers

ECG as primary cardiac test

Troponin

Diagnostic Tests

Scoring Systems

ECG-based risk stratification

Clinical severity assessment

MRI

MRI role in TCA toxicity

CT

CT head indications

CT chest or abdomen role

Ultrasound

Point-of-care cardiac POCUS

Vascular access guidance

Disposition

Admission criteria

All TCA overdoses require hospital admission

ICU admission indications

High-acuity admission triggers

Medical clearance criteria

Criteria for medical clearance before psychiatric disposition

Transfer considerations

Transfer indications

Treatment

Sodium bicarbonate therapy

Sodium bicarbonate indications

Dosing protocol

Seizure management

First-line anticonvulsants

Second-line anticonvulsants

Vasopressor and hemodynamic support

Hypotension management

Avoid vasopressors with adrenergic agonism that may worsen arrhythmias

Antiarrhythmic therapy

For wide-complex tachycardia refractory to sodium bicarbonate

Absolutely contraindicated antiarrhythmics

Rescue therapies

Intravenous lipid emulsion

Veno-arterial ECMO

Mechanical ventilation strategy

Intubated patient alkalinization

Avoid respiratory acidosis

Contraindicated treatments

Physostigmine

Flumazenil

Induced emesis

Special Populations

Pregnancy

Pregnancy-specific considerations

Maternal management priorities

Fetal monitoring

Geriatric

Pharmacokinetic and pharmacodynamic changes

Clinical presentation differences

Management modifications

Pediatrics

Pediatric sensitivity to TCA toxicity

Weight-based dosing

Pediatric intravenous lipid emulsion

Background

Epidemiology

Incidence and clinical burden

Mortality patterns

Pathophysiology

Primary toxicity mechanisms

Effect of acidosis on toxicity

ECG changes and mechanism

Therapeutic Considerations

Alkalinization rationale

Decontamination considerations

Pharmacokinetics and clearance

Patient Discharge Instructions

copy discharge instructions

Tricyclic antidepressant poisoning: going home

Return to the emergency room immediately if you have

Follow up appointments

Important reminders

References

Guidelines and key sources

American Heart Association guidelines

Toxicology-specific evidence

Pediatric evidence

Regulatory and prescribing information

Coding reference