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Severe symptoms may occur abruptly within 30–60 min after acute tricyclic antidepressant overdose
Prolongation of the QT interval and torsades de pointes have been reported with several of the newer antidepressants
Life-threatening hyperthermia may result from status epilepticus and anticholinergic-induced impairment of sweating
Serotonin syndrome should be suspected if agitation, delirium, diaphoresis, tremor, hyperreflexia, clonus (spontaneous, inducible, or ocular), and fever develop in a patient taking serotonin reuptake inhibitors
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Observe patients for at least 6 h
Admit patients if there are anticholinergic effects or signs of cardiotoxicity
Administer activated charcoal 60–100 g mixed in aqueous slurry orally or via gastric tube
Consider gastric lavage after recent large ingestions
Treat cardiotoxic effects with boluses of sodium bicarbonate (50–100 mEq intravenously)
Prolongation of the QT interval or torsades de pointes is usually treated with intravenous magnesium or overdrive pacing
Severe cardiotoxicity in patients with overdoses of lipid-soluble drugs (eg, amitriptyline, bupropion) has responded to intravenous lipid emulsion (Intralipid), 1.5 mL/kg repeated one to two times if needed
Plasma exchange using albumin and extracorporeal membrane oxygenation (ECMO) has been reported successful in several cases
Serotonin syndrome
Mild: may be treated with benzodiazepines and withdrawal of the antidepressant
Moderate: may respond to cyproheptadine (4 mg orally or via gastric tube hourly for three or four doses) or chlorpromazine 25 mg intravenously
Severe hyperthermia should be treated with neuromuscular paralysis and endotracheal intubation in addition to external cooling measures