Key messages

• Tricyclic antidepressants can be fatal in overdose owing to cardiac arrhythmias resulting from their proarrhythmic effect or profound hypotension resulting from their negative inotropic effect.

• Because tricyclic drugs delay gastric emptying, peak plasma levels occur within 2 to 8 h of a therapeutic dose, and peak overdose toxicity is usually seen within 6 h of ingestion.

• In cases seen within 2 h of ingestion, gastric lavage followed by 50 g of activated charcoal is indicated.

• All patients should be observed with ECG monitoring for at least 6 h after ingestion.

• If the patient is showing signs of worsening toxicity, has cardiovascular instablity or a wide QRS complex on the ECG, or is acidotic, sodium bicarbonate should be administered to maintain the arterial blood pH between 7.45 and 7.55.

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