If signs of toxicity occur at any time during this period, extended monitoring is required. Monitoring of plasma drug levels should not guide management of the patient. All patients suspected of tricyclic antidepressant overdose should receive gastrointestinal decontamination. This should include large volume gastric lavage followed by activated charcoal. If consciousness is impaired, the airway should be secured prior to lavage.
Emesis is contraindicated.
In rare instances, hemoperfusion may be beneficial in acute refractory cardiovascular instability in patients with acute toxicity. However, hemodialysis, peritoneal dialysis , exchange transfusions, and forced diuresis generally have been reported as ineffective in tricyclic antidepressant poisoning. In patients with CNS depression , early intubation is advised because of the potential for abrupt deterioration. Physostigmine is not recommended except to treat life- threatening symptoms that have been unresponsive to other therapies, and then only in consultation with a poison control center. Psychiatric referral may be appropriate.