OVERDOSE
Overdoses are common. They can be intentional or non-intentional. Intentional overdose may be a manifestation of a suicide attempt. Unintentional overdose can be the result of confusion over taking prescription medications or misuse of recreational or illicit drugs. Overdoses of psychiatric psychoactive medications pose a unique challenge. Often these overdoses involve more than one medication confusing the presentation and management of the patient.
General treatment of overdoses
1. The patient needs a comprehensive history taken including all medications and a physical examination.
2. A search for prescription bottles must be undertaken and an estimate made of the types and quantity of medications that may have been taken.
3. Any history of a recreational drug or illicit drug should be investigated.
4. The patient should be evaluated with a monitor that can obtain vital signs, pulse oximetry, end tidal CO2 and the cardiac rhythm.
5. Oxygen should be given if indicated.
6. Intravenous access should be obtained if indicated.
7. Suicide interventions should be conducted if needed.
8. The New Mexico Poison Control Center offers excellent information if more is needed for the evaluation, treatment, and monitoring of overdose patients. (800) 222-1222.
9. Overdose patients should be transported to an appropriate medical facility for evaluation and treatment.
Medical Interventions
1. TRICYCLIC ANTI-DEPRESSANTS
A. These highly toxic medications often produce serious and occasionally fatal results when overdosed. Expeditious transport to an appropriate medical facility should be undertaken once the patient is prepared for treatment and transport.
B. In addition to monitoring a 12-lead EKG should be obtained.
C. Common arrythmias associated with tricyclic overdoses include a variety of AV blocks, sinus and ventricular tachycardias, prolongation of the PR, QRS, and QT intervals and rarely Torsades.
i. Arrythmias that compromise the patient’s hemodynamic stability or are a threat such as Ventricular Tachycardia with a pulse should be treated with intravenous SODIUM BICARBANATE. This may need to be repeated to contain the arrythmia.
ii. CPR and cardiopulmonary resuscitation may be required.
iii. Hypotension should be managed with fluid resuscitation. Shock states may require a vasopressor. NOREPINEPHRINE is recommended. See LCFD Treatment Guidelines for dosing.
D. Some examples of Tricyclic Anti-Depressants in common use include Amitriptyline, Nortriptyline, Imipramine, Desipramine, and Doxepin. There are others less commonly prescribed.
2. BENZODIAZEPINES
A. These medications have a wide safety range but can prove fatal especially when taken with other sedating medications or alcohol. Sedation and compromise of breathing are the most common results of overdose.
B. The treatment is primarily supportive. This includes maintaining a patent airway, ensuring adequate ventilation and oxygenation, and supporting blood pressure.
SECOND GENERATION ANTI-DEPRESSANTS
1. SSRI, SNRI
A. This is a large class of medications including Fluoxetine, Sertaline, Citalopram, Escitalopram. The SNRI’s include Duloxetine, Venlafaxine, and Desvenlafaxine. There are many others
B. Overdoses with this class of drugs generally have a favorable outcome with proper monitoring and supportive care.
C. Signs and symptoms include: Muscle spasms (Clonus), Tremors, Sweating, Dilated pupils, Tachycardia, Tachypnea, Confusion, Agitation, and Delirium.
D. Treatment is largely supportive. Maintaining a patent airway and ensuring adequate ventilation and oxygenation are important.
E. KETAMINE is not recommended in treating these patients for undifferentiated severe agitation or delirium.
2. BUPROPRION
A. This unique antidepressant is potentially more toxic than the SSRI and SNRI anti-depressants. It is in common usage.
B. Signs and symptoms include Tachycardia, Drowsiness, Agitation, Hallucinations, Vomiting, Tremors, and in severe cases Seizures.
C. Cardiac toxicity is rare but reported. Prolongation of the QRS and QT can be seen along with various arrythmias. Hypotension can occur.
D. Seizures should be treated as any other seizure. MIDAZOLAM IM is the treatment of choice. See the LCFD SEIZURE Treatment Guideline for dosing.
E. Hypotension should be treated with fluids.
3. MAO INHIBITORS
These highly toxic medications are not in common usage.
A. The toxidrome is primarily adrenergic over stimulation. Signs and symptoms are many including Altered Mental Status, Coma, Agitation, Sweating, Tachycardia, Vomiting, Seizures, Cardiorespiratory compromise, Muscle rigidity and Myoclonus (Muscle Spasms), and Fever.
B. Cardiac toxicity is reported and includes a variety of arrythmias and hypertension.
C. Treatment is largely supportive including securing a patent airway and ensuring adequate ventilation and oxygenation.
D. Seizures should be managed as any other seizure with MIDAZOLAM IM. See the LCFD Treatment Guidelines for dosing.
E. Expeditious transport should be obtained.
SECOND GENERATION (ATYPICAL) ANTI-PSYCHOTICS
A. Much more commonly prescribed than the first-generation anti-psychotic agents these include Resperidone, Quetiapine, Olanzapine, Aripiprazole, and Clozipine with other newer agents coming on the market rapidly.
B. The signs and symptoms are often complicated by multiple medications being ingested. There are very often multiple medications prescribed. The signs and symptoms include Delirium, Fever, Tachycardia, Blurred vision, Red Dry Skin, Agitation, Hallucinations, Mumbling Speech. The patient rarely recalls the event.
C. Cardiac toxicity has been reported with QT interval prolongation. Torsades is rarely reported, however.
D. Treatment is largely supportive care ensuring a patent airway and adequate ventilation and oxygenation.
E. Hypotension if it occurs should be managed with fluids.
LITHUM
A. Lithium has been used as a mood stabilizer in bipolar disorder for over a century. It has a narrow range of safety and unintentional overdose is common.
B. Symptoms and signs vary with the serum concentration of Lithium. They range from Tremor, Overactive Reflexes, Nystagmus (eye tremor), and Ataxia (poor muscle control) to more severe symptoms and signs of Confusion, Agitation, Delirium, and Tachycardia leading to Coma, Seizures, Fever, and Hypotension.
C. Cardiac toxicity is usually non-specific and mild.
D. Treatment is largely supportive. Ensure a patent airway and adequate ventilation and oxygenation.
E. Hypotension should be managed with fluids.
F. Seizures are rare and can be managed with MIDAZOLAM. See the LCFD Treatment Guidelines for dosing.
Overdoses are common. They can be intentional or non-intentional. Intentional overdose may be a manifestation of a suicide attempt. Unintentional overdose can be the result of confusion over taking prescription medications or misuse of recreational or illicit drugs. Overdoses of psychiatric psychoactive medications pose a unique challenge. Often these overdoses involve more than one medication confusing the presentation and management of the patient.
General treatment of overdoses
1. The patient needs a comprehensive history taken including all medications and a physical examination.
2. A search for prescription bottles must be undertaken and an estimate made of the types and quantity of medications that may have been taken.
3. Any history of a recreational drug or illicit drug should be investigated.
4. The patient should be evaluated with a monitor that can obtain vital signs, pulse oximetry, end tidal CO2 and the cardiac rhythm.
5. Oxygen should be given if indicated.
6. Intravenous access should be obtained if indicated.
7. Suicide interventions should be conducted if needed.
8. The New Mexico Poison Control Center offers excellent information if more is needed for the evaluation, treatment, and monitoring of overdose patients. (800) 222-1222.
9. Overdose patients should be transported to an appropriate medical facility for evaluation and treatment.
Medical Interventions
1. TRICYCLIC ANTI-DEPRESSANTS
A. These highly toxic medications often produce serious and occasionally fatal results when overdosed. Expeditious transport to an appropriate medical facility should be undertaken once the patient is prepared for treatment and transport.
B. In addition to monitoring a 12-lead EKG should be obtained.
C. Common arrythmias associated with tricyclic overdoses include a variety of AV blocks, sinus and ventricular tachycardias, prolongation of the PR, QRS, and QT intervals and rarely Torsades.
i. Arrythmias that compromise the patient’s hemodynamic stability or are a threat such as Ventricular Tachycardia with a pulse should be treated with intravenous SODIUM BICARBANATE. This may need to be repeated to contain the arrythmia.
ii. CPR and cardiopulmonary resuscitation may be required.
iii. Hypotension should be managed with fluid resuscitation. Shock states may require a vasopressor. NOREPINEPHRINE is recommended. See LCFD Treatment Guidelines for dosing.
D. Some examples of Tricyclic Anti-Depressants in common use include Amitriptyline, Nortriptyline, Imipramine, Desipramine, and Doxepin. There are others less commonly prescribed.
2. BENZODIAZEPINES
A. These medications have a wide safety range but can prove fatal especially when taken with other sedating medications or alcohol. Sedation and compromise of breathing are the most common results of overdose.
B. The treatment is primarily supportive. This includes maintaining a patent airway, ensuring adequate ventilation and oxygenation, and supporting blood pressure.
SECOND GENERATION ANTI-DEPRESSANTS
1. SSRI, SNRI
A. This is a large class of medications including Fluoxetine, Sertaline, Citalopram, Escitalopram. The SNRI’s include Duloxetine, Venlafaxine, and Desvenlafaxine. There are many others
B. Overdoses with this class of drugs generally have a favorable outcome with proper monitoring and supportive care.
C. Signs and symptoms include: Muscle spasms (Clonus), Tremors, Sweating, Dilated pupils, Tachycardia, Tachypnea, Confusion, Agitation, and Delirium.
D. Treatment is largely supportive. Maintaining a patent airway and ensuring adequate ventilation and oxygenation are important.
E. KETAMINE is not recommended in treating these patients for undifferentiated severe agitation or delirium.
2. BUPROPRION
A. This unique antidepressant is potentially more toxic than the SSRI and SNRI anti-depressants. It is in common usage.
B. Signs and symptoms include Tachycardia, Drowsiness, Agitation, Hallucinations, Vomiting, Tremors, and in severe cases Seizures.
C. Cardiac toxicity is rare but reported. Prolongation of the QRS and QT can be seen along with various arrythmias. Hypotension can occur.
D. Seizures should be treated as any other seizure. MIDAZOLAM IM is the treatment of choice. See the LCFD SEIZURE Treatment Guideline for dosing.
E. Hypotension should be treated with fluids.
3. MAO INHIBITORS
These highly toxic medications are not in common usage.
A. The toxidrome is primarily adrenergic over stimulation. Signs and symptoms are many including Altered Mental Status, Coma, Agitation, Sweating, Tachycardia, Vomiting, Seizures, Cardiorespiratory compromise, Muscle rigidity and Myoclonus (Muscle Spasms), and Fever.
B. Cardiac toxicity is reported and includes a variety of arrythmias and hypertension.
C. Treatment is largely supportive including securing a patent airway and ensuring adequate ventilation and oxygenation.
D. Seizures should be managed as any other seizure with MIDAZOLAM IM. See the LCFD Treatment Guidelines for dosing.
E. Expeditious transport should be obtained.
SECOND GENERATION (ATYPICAL) ANTI-PSYCHOTICS
A. Much more commonly prescribed than the first-generation anti-psychotic agents these include Resperidone, Quetiapine, Olanzapine, Aripiprazole, and Clozipine with other newer agents coming on the market rapidly.
B. The signs and symptoms are often complicated by multiple medications being ingested. There are very often multiple medications prescribed. The signs and symptoms include Delirium, Fever, Tachycardia, Blurred vision, Red Dry Skin, Agitation, Hallucinations, Mumbling Speech. The patient rarely recalls the event.
C. Cardiac toxicity has been reported with QT interval prolongation. Torsades is rarely reported, however.
D. Treatment is largely supportive care ensuring a patent airway and adequate ventilation and oxygenation.
E. Hypotension if it occurs should be managed with fluids.
LITHUM
A. Lithium has been used as a mood stabilizer in bipolar disorder for over a century. It has a narrow range of safety and unintentional overdose is common.
B. Symptoms and signs vary with the serum concentration of Lithium. They range from Tremor, Overactive Reflexes, Nystagmus (eye tremor), and Ataxia (poor muscle control) to more severe symptoms and signs of Confusion, Agitation, Delirium, and Tachycardia leading to Coma, Seizures, Fever, and Hypotension.
C. Cardiac toxicity is usually non-specific and mild.
D. Treatment is largely supportive. Ensure a patent airway and adequate ventilation and oxygenation.
E. Hypotension should be managed with fluids.
F. Seizures are rare and can be managed with MIDAZOLAM. See the LCFD Treatment Guidelines for dosing.