Tricyclic Antidepressants (TCA)

Agents (Selected Agents)

  • Amitriptyline (Tryptomer, Elavil) (see Amitriptyline, [[Amitriptyline]])
  • Clomipramine (Anafranil) (see Clomipramine, [[Clomipramine]])
  • Desipramine (Norpramin, Pertofrane) (see Desipramine, [[Desipramine]])
  • Doxepin (Adapin, Sinequan) (see Doxepin, [[Doxepin]])
  • Imipramine (Tofranil, Janimine, Praminil) (see Imipramine, [[Imipramine]])
  • Nortriptyline (Pamelor, Aventyl, Norpress) (see Nortriptyline, [[Nortriptyline]])
  • Protriptyline (Vivactil) (see Protriptyline, [[Protriptyline]])
  • Trimipramine (Surmontil) (see Trimipramine, [[Trimipramine]])

Adverse Effects

Cardiovascular Adverse Effects

  • QT Prolongation with Variable Association with Torsade (see Torsade, [[Torsade]]): all tricyclic antidepressants cause QT prolongation, but only a few have been definitively associated with torsade
    • Desipramine (Norpramin, Pertofrane) (see Desipramine, [[Desipramine]])
    • Doxepin (Adapin, Sinequan) (see Doxepin, [[Doxepin]])
    • Imipramine (Tofranil, Janimine, Praminil) (see Imipramine, [[Imipramine]])

Neurologic Adverse Effects

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Other Adverse Effects

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Tricyclic Antidepressant (TCA) Intoxication

Epidemiology

  • Tricyclic overdose is one of the most common drug emergencies in the ED
  • Higher drug levels correlate with higher risk of pulmonary complications
  • 33% of pulmonary complications in tricyclic overdose are either ALI-ARDS or aspiration pneumonia
  • 80% of cases have widened A-a gradient on presentation
  • 50% of cases have an abnormal CXR

Physiology

  • Quinidine-Like Effect
  • Anticholinergic Effec
  • Blockade of Norepinephrine Re-Uptake
  • Antihistamine-Like Effect

Clinical Manifestations

Cardiovascular Manifestations

  • Hypotension (see Hypotension, [[Hypotension]])
  • Decreased Myocardial Contractility/Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
  • Bradycardia (see Bradycardia, [[Bradycardia]])
  • Widened QRS
  • P-R Prolongation
  • Q-T Prolongation
  • Ventricular Arrhythmias

Neurologic Manifestations

Pulmonary Manifestations

  • Acute Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
    • Epidemiology: mechanical ventilation is required in 75% of tricyclic overdoses
  • Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
    • Epidemiology: occurs in 10% of TCA overdoses
  • Aspiration Pneumonia (see Aspiration Pneumonia, [[Aspiration Pneumonia]])
    • Epidemiology: common in tricyclic overdose

Treatment

  • Activated Charcoal
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References

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