EPIDEMIOLOGY TCA & MAOI - PowerPoint Presentation

EPIDEMIOLOGY TCA & MAOI
EPIDEMIOLOGY TCA & MAOI

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firstgeneration antidepressant Antidepressants third most common cause of drugrelated fatalities cyclic antidepressants the most commonly identified class of antidepressants to cause overdoserelated ID: 909019 Download Presentation

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cyclic seizures patients sodium seizures cyclic sodium patients antidepressants hours antidepressant tachycardia qrs toxicity cardiac therapy sinus abnormalities levels

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Slide1

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EPIDEMIOLOGY

TCA & MAOI

first-generation antidepressant.Antidepressants third most common cause of drug-related fatalities .

cyclic antidepressants

the most commonly identified class of antidepressants to cause overdose-related deaths.!

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PHARMACOKINETICS

peak plasma levels :

between 2 and 6 hours Tissue cyclic antidepressant levels :

10 to 100

times greater than plasma levels.

Attempts to remove cyclic antidepressants by hemodialysis,hemoperfusion,

peritoneal dialysis, or forced diuresis generally are

unproductive.

Slide7

The average half-life of cyclic antidepressants

24 hours (range, 6 to 36 hours).

Slide8

TOXICITY

patients at

higher risk for cyclic antidepressant toxicity include who have medication such as:Cardiotoxic

Sedative-hypnotic

Geriatric

patients, underlying heart or neurologic

disease.

Slide9

Desipramine

Most potent sodium channel blocker

Precipitate severe cardiotoxicity (e.g.,

wide QRS

complex,

hypotension) It is associated with a higher fatality rate

than the other cyclic antidepressants

Slide10

Amoxapine

and maprotiline

Associated with greater toxicity than other cyclic antidepressants, especially in regard to causing seizures.

Slide11

CLINICAL FEATURES

Mild

antimuscarinic symptoms: (dry mouth and

axillae,sinus

tachycardia)

Severe cardiotoxicity secondary to sodium channel blockade.

Slide12

Most common symptom

:

Altered mental status.

(GCS of <8 in the ED

is a strong predictor of serious complications such as

seizures and cardiac dysrhythmias

)Most frequent dysrhythmia:

Sinus tachycardia.

Slide13

Serious toxicity

within

6 hours of major cyclic antidepressant

ingestion and consists of:

coma

cardiac conduction delays supraventricular

tachycardia hypotension respira

tory depression ventricular tachycardia

seizures

Slide14

Secondary complications

Apiration

pneumoniaAnoxic encephalopathyHyperthermia.

Rhabdomyolysis

.

Pulmonary edema

Slide15

Seizures

Generalized and of brief duration.

Exception : amoxapine

and

maprotiline

(these agents can cause status epilepticus.)

Slide16

DIAGNOSIS

Urine tests

Cannot differentiate between therapeutic and toxic levels. False positive results have been reported for a number of medications such as :

carbamazepine

. cetirizine, cyclobenzaprine

. cyproheptadine. diphenhydramine

, hydroxyzine. quetiapine.

phenothiazines

(e.g.•

thioridazine

).

Slide17

ECG abnormalities

The classic ECG with cyclic antidepressant

toxicity:(sinus tachycardia

,

right axis deviation

and prolongation of the PR,QRS. and QT intervals)

Slide18

ECG abnormalities

develop within

6 hours of ingestion and typically resolve over 36 to

48

hr.

The identification of either QRS complex widening of >100 ms, right axis deviation of > 120 degrees, or a

Brugada pattern warrants sodium bicarbonat

therapy and admission to a ICU.

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TREATMENT

Evaluation for

: alterations of consciousness.

hemodynamic instability

respiratory impairment.

IV line Continuous cardiac rhythm monitoring

Serial ECGs laboratory studies (electrolyte. creatinine. and glucose level)

Serum acetaminophen level ABG

Slide25

Antimuscarinic

symptoms

: urinary catheterization nasogastric

tube

Patients who are initially asymptomatic may deteriorate rapidly and therefore should be

monitored closely for 6 hours.

Slide26

GI DECONTAMINATION

ipecac syrup cannot be recommended

charcoal

single 1 gram/kg dose.

gastric lavage

Slide27

• SODIUM BICARBONATE THERAPY:

Indications:

- Hypotension refractory to fluid hydration.

-

Cardiac conduction abnormalities

(e.g., prolonged QRS duration or Brugada pattern), -Ventricular

dysrhythmias.

Slide28

SODIUM BICARBONATE THERAPY

IV bolus of

1 to 2 mEq/kg.

which can be repeated until patient

improvement

is noted or until blood pH equals 7.50 to 7.55

Slide29

ALTERED LEVEL OF CONSCIOUSNESS

Coma

is rapid in onset and serves as a predictive factor for development of cardiotoxicity and/or seizures.Flumazenil

Reassurance. decreased environmental stimulation. and benzodiazepines.

Physostigmine

Slide30

SEIZURES

Seizures are

generalized and of brief duration.Focal seizures are atypical and should prompt further neurologic evaluation.

Seizures are common with

maprotiline

& amoxapine ingestions and require aggressive management. Because status epilepticus

is frequently associated with them.

Slide31

Benzodiazepines

( diazepam,

lorazepam) are the anticonvulsants of

choice

to stop existing seizure activity

Seizures resistant to benzodiazepine: Barbiturates(e.g .•

phenobarbital)Endotracheal intubation and respiratory support are required when benzodiazepines are combined with barbiturates or

propofol.

Slide32

HYPOTENSION

1..Treated with isotonic crystalloid fluids in IV boluses

10 ml/kg.2.. does not improve:

sodium bicarbonate

3.. does not improve:

vasopressor most effective:

norepinephrine (1 microgram/min to 30 micrograms/min.)

Slide33

CARDIAC CONDUGION ABNORMALITIES

AND DYSRHYTHMIAS

Asymptomatic patients with

sinus tachycardia

,

isolated PR interval prolongation or first-degree atrioventTicular block do not require specific pharmacologic therapy.

Slide34

Asymptomatic or mildly toxic patients with

isolated QRS complex prolongation

(QRS duration is > 100 milliseconds) should be treated with sodium bicarbonate

therapy.

Hyperventilation Hypertonic saline

Slide35

Ventricular

dysrhythmias

: sodium bicarbonatesecond agent of choice: Lidocaine

Slide36

Contraindicated medications

all class

Ia and Ic antiarrhythmic

agents,

B blockers Calcium channel blockers

all class III antiarrhythmic agents.

Slide37

Intravenous lipid emulsion:

20% lipid emulsion 100 mL IV bolus

over 1 minute. followed by 400

mL

IV over 20 minutes in patients with life-thTeatening cyclic antidepressant induced cardiotoxicity that is refractory to other measures

Slide38

DISPOSITION AND FOLLOW-UP

Asymptomatic after 6 hours

of observation do not require hospital admission for toxicologic reasons.

All symptomatic patients :

hospital admission

.signs of moderate to severe toxicity: ICU

Slide39

Shom More....