Abstract
Tricyclic antidepressants (TCAs) account for approximately 3% of all pediatric hospitalizations due to poisoning. TCAs remain a common cause of fatal drug poisoning because of their cardiovascular toxicity as manifested by electrocardiogram (ECG) abnormalities, arrhythmias, and hypotension. We report a 15-year-old girl with junctional escape rhythm and resistant hypotension caused by severe imipramine intoxication. Initial ECG showed junctional escape rhythm (46 bpm) with no atrial activity, low QRS voltage, widening of the QRS complex (160 ms) with a right bundle branch-like pattern, R wave > 3 mm in aVR (6 mm), and prolongation of the QT interval (QTc 550 ms). Despite intravenous fluids and inotropic support, she had resistant hypotension and acute renal failure. Junctional rhythm was successfully terminated by using temporary cardiac pacemaker. Hemodialysis and hemoperfusion were also performed. She was discharged on the day 5 without any complications. During follow-up, no ECG abnormalities were noted. We reported successful use of temporary cardiac pacemaker for treatment of junctional rhythm and resistant hypotension in imipramine intoxication. The conventional methods of activated charcoal, alkalinization, and symptomatic treatment of complications are usually enough for nonlethal doses of TCA intoxication. However, in imipramine intoxication with serious arrythmias and hypotension, using temporary cardiac pacemaker, hemodialysis, and hemoperfusion can be a life-saving therapeutic approach.
References
Boehnert MT, Lovejoy FH Jr (1985) Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med 313:474–479
Brennan FJ (1980) Electrophysiological effects of imipramine and doxepin on normal and depressed cardiac purkinje fibers. Am J Cardiol 46:599–606
Caksen H, Akbayram S, Odabaş D, Ozbek H, Erol M, Akgün C et al (2006) Acute amitriptyline intoxication: an analysis of 44 children. Hum Exp Toxicol 25:107–110
Diaz-Buxo JA, Farmer CD, Chandler JT (1978) Hemoperfusion in the treatment of amitriptyline intoxication. Trans Am Soc Artif Intern Organs 24:699–703
Dziukas LJ, Vohra J (1991) Tricyclic antidepressant poisoning. Med J Aust 154:344–350
Heath A, Wickström I, Martensson E, Ahlmen J (1982) Treatment of antidepressant poisoning with resin hemoperfusion. Human Toxicol 1:361–371
Hulten BA, Heath A (1983) Clinical aspects of tricyclic poisoning. Acta Med Scand 213:275–278
James LP, Kearns GL (1995) Cyclic antidepressant toxicity in children and adolescents. J Clin Pharmacol 35:343–350
Thanacoody HK, Thomas SH (2005) Tricyclic antidepressant poisoning: cardiovascular toxicity. Toxicol Rev 24:205–214
Thorstrand C (1976) Clinical features in poisonings by tricyclic antidepressants with special reference to the ECG. Acta Med Scand 199:337–344
Woolf AD, Erdman AR, Nelson LS, Caravati EM, Cobaugh DJ, Booze LL et al (2007) Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol 45:203–233
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sert, A., Aypar, E., Odabas, D. et al. Temporary Cardiac Pacemaker in the Treatment of Junctional Rhythm and Hypotension Due to Imipramine Intoxication. Pediatr Cardiol 32, 521–524 (2011). https://doi.org/10.1007/s00246-011-9914-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00246-011-9914-y