Joseph Baus, MD
Physician
University of Nebraska Medical Center, United States
Disclosure information not submitted.
Chandni Ravi, MD
Critical Care Fellow
University Of Nebraska Medical Center, United States
Disclosure information not submitted.
Dennis Thiel, MD
Physician
University of Nebraska Medical Center, United States
Disclosure information not submitted.
Title: Tricyclic Antidepressant Overdose Managed With Veno-Arterial Extracorporeal Membrane Oxygenation Case Report Body:
Introduction: Tricyclic Antidepressants (TCAs) were used extensively in depression and other psychiatric disorders in the 1950s through the 1980s. Use has declined over the last few decades, but they are still routinely used in the treatment of depression and management of disorders such as migraines, chronic pain, and insomnia. Here we present a case of a TCA overdose leading to cardiac arrest that was successfully managed with transvenous pacing, high dose pressors, intravenous (IV) lipid emulsion therapy, and veno-arterial extracorporeal membrane oxygenation (VA ECMO).
Description: A 44-year-old female with a history of borderline personality disorder, depression, and substance abuse presented to the emergency department with a reported overdose on her prescribed Amitriptyline. On arrival to the emergency department, she was unresponsive and subsequently intubated. She became progressively hypotensive and bradycardic and went into cardiac arrest. Return of spontaneous circulation was achieved after a few rounds of CPR. She had progressive prolongation of her QRS complex, which is commonly seen in TCA overdose. She was then given 1 gram of calcium chloride, 3 amps of sodium bicarbonate, activated charcoal and 20% intralipid intravenous fat emulsion. She continued to deteriorate hemodynamically requiring vasopressin and high doses (45mcg/min) of norepinephrine and epinephrine. A transvenous pacemaker was placed for refractory bradycardia resulting in mild improvement in her rate but without change in her blood pressure. She was therefore cannulated peripherally for VA ECMO. Over the next four days in the intensive care unit, she showed progressive hemodynamic improvement. She had the transvenous pacemaker removed and was decannulated from ECMO on hospital day four. She remained off pressors and was extubated on hospital day five. She was transferred to the floor on hospital day six neurologically intact and subsequently discharged to the inpatient psychiatric unit at another institution.
Discussion: TCA overdoses can lead to devastating cardiovascular and central nervous system toxicity. This case demonstrates the use of VA ECMO as another modality for supporting these patients in cases of life-threatening overdose leading to cardiovascular collapse.