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]])

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]])

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

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

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