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The management of agitation following tricyclic antidepressant overdose: Is sedation safe?

Three Part Question

In [agitated adult patients who present to the Emergency Department after an overdose of tricyclic antidepressant drugs] does [the use of sedative agents] lead to [an acceptably low rate of pulmonary aspiration]?

Clinical Scenario

A burly thirty year-old man presents to the Emergency Department having taken a significant overdose of tricyclic antidepressant drugs. He is agitated and confused and it is not possible to treat him effectively. You wonder whether it will be safe to sedate him, given that you will depress his conscious level and the tricyclic antidepressants will delay gastric emptying, increasing the risk of pulmonary aspiration.

Search Strategy

Ovid Medline 1950 - May Week 2 2008
Ovid Embase 1980 - 2008 Week 21
[exp Antidepressive Agents, Tricyclic/ or or or exp Amitriptyline/ or or exp Desipramine/ or or exp Clomipramine/ or or exp Doxepin/ or or exp Dothiepin/ or or exp Imipramine/ or or exp Lofepramine/ or or exp Nortriptyline/ or or exp Trimipramine/] AND [exp Overdose/ or exp Poisoning/ or] AND [exp "Hypnotics and Sedatives"/ or or sedat$.mp. or hypnotic$.mp.] AND [exp Aspiration/ OR exp Aspiration Pneumonitis/ OR exp Aspiration Pneumonia/ OR exp Mendelson Syndrome/ OR exp Airway/ OR OR OR] limit to humans and English language

Search Outcome

2 papers were found using Medline and 32 using Embase. None were relevant to the three-part question.


There is no evidence of harm when intravenous sedation is administered in agitated patients who have taken an overdose of tricyclic antidepressant agents. The National Poisons Information Service recommends the use of benzodiazepines to control delirium in this situation ( Because tricyclic antidepressant agents are known to delay gastric emptying and many patients who have taken an overdose have also consumed a large amount of alcohol it would be advisable to exercise caution when sedating these patients. When there is doubt regarding a patient's protective airway reflexes endotracheal intubation may be necessary. However there is no evidence to suggest that sedation should not be attempted in these patients.

Clinical Bottom Line

There is no evidence of harm when sedating agitated patients following tricyclic antidepressant overdose. National Poisons Information Service guidance advocates the use of benzodiazepines to control delirium in this situation. Caution should be exercised in view of the potential risks of pulmonary aspiration.