A review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B). 4) Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department: an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose. For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5 mg/kg. For despiramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; and for protriptyline it is >1 mg/kg. This recommendation applies to both patients who are naive to the specific TCA and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grades B/C). 5) Do not induce emesis (Grade D). 6) The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D). 7) For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C). 8) Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D). 9) An ECG or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B). 10) Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard ACLS guidelines (Grade D). 11) Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D). 12) For TCA-associated convulsions, benzodiazepines are recommended (Grade D). 13) Flumazenil is not recommended for patients with TCA poisoning (Grade D).

https://www.tandfonline.com/doi/pdf/10.1080/15563650701226192

Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management*

A case of meningeal melanocytoma at the foramen magnum is reported in a 62-year-old man. Magnetic resonance (MR) imaging revealed characteristic signal patterns: homogeneous high intensity on the T1-weighted image and low intensity on the T2-weighted image. Light microscopy showed a histological appearance similar to that of melanotic meningioma. The ultrastructural features of the neoplastic cells were compatible with those of melanocytes, but they contained no features of arachnoidal cells. Immunohistochemical bromodeoxyuridine study revealed low proliferative activity among the neoplastic cells. The MR appearance and pathological features in this rare case of meningeal melanocytoma are demonstrated and discussed.

Meningeal melanocytoma: magnetic resonance imaging characteristics and pathological features. Case report.

A case of meningeal melanocytoma, the 14th in the literature, is presented. Neurodiagnostic imaging, with both computed tomographic scan and magnetic resonance imaging, is included. Pathological examination of the tumor consisted of light microscopy, electron microscopy, and immunohistochemistry. The literature is reviewed and pathological criteria are presented to distinguish meningeal melanocytoma from meningiomas containing melanin pigment and from malignant melanoma.

Meningeal melanocytoma: diagnostic criteria for a rare lesion.

Meningeal melanocytomas are uncommon lesions They are generally considered to be benign tumors that derive from leptomeningeal melanocytes A rare case of a metastatic spinal meningeal melanocytoma is presented All relevant cases reported in literature since 1972, when the term "meningeal melanocytoma" was first used, were reviewed Rates of tumor recurrence from 1 to 5 years were calculated for this rare lesion, based on published data and on additional information obtained from personal contact with most of the authors Recurrency rates of 47 patients suitable for evaluation were correlated with the different therapeutic approaches Complete tumor resection alone and incomplete resection alone followed by irradiation appeared to be superior to incomplete resection alone in terms of disease-free survival Statistical significance was achieved for complete tumor resection at follow up between I and 4 years (range p = 0010-0050) and for incomplete resection combined with radiotherapy after 2 years (p = 0034) Complete tumor resection should be considered the best therapeutic option, followed by incomplete resection combined with postoperative radiotherapy

Therapeutic options for meningeal melanocytoma. Case report.

OBJECTIVE To review poisoning with tricyclic antidepressants DATA SOURCE English language literature search using Australian Medlars Service (1977-1989), manual search of journals and review of bibliographies in identified articles STUDY SELECTION Approximately 250 articles, abstracts and book chapters were selected for analysis DATA EXTRACTION The literature was reviewed and 93 articles were selected as representative of important advances DATA SYNTHESIS The major features of overdose are neurological, cardiac, respiratory and anticholinergic Life-threatening complications develop within six hours of overdose or not at all All patients seen within six hours of overdose should have their stomachs emptied All patients should receive activated charcoal Coma, convulsions, respiratory depression and hypotension are treated with standard resuscitation techniques and drugs Treat patients with significant cardiotoxicity or cardiac arrest with alkalinisation by sodium bicarbonate or hyperventilation, aiming for an arterial pH of 745-755 Lignocaine is used for ventricular arrhythmias Other antiarrhythmic drugs are contraindicated (Class 1A, Class 1C), potentially lethal (Class II), of no benefit (phenytoin) or of unproven efficacy (Class III and Class IV) Physostigmine has no role at all Haemodialysis and haemoperfusion are of no benefit CONCLUSION The death rate of those who reach hospital is 2%-3% Most of these deaths are cardiac in origin, and are caused by direct depression of myocardial function rather than cardiac arrhythmias

Tricyclic antidepressant poisoning.

Une observation de tentative de suicide. Premier cas publie de polyradiculonevrite. Traitement efficace par reanimation

/pdf/acute-polyradiculoneuropathy-after-amitriptyline-overdose-3wm1im26r7.pdf

Acute polyradiculoneuropathy after amitriptyline overdose.

Melanotic tumours of the central nervous system constitute a group of expanding lesions whose prognosis is variable, depending upon their histopathological nature. The report of this case of melanotic meningioma finds its interest in the exceptional nature of this type of tumour and in the difficulty of ascertaining whether it is benign or malignant.

Melanotic meningioma. Report of a case and review of the literature.

The authors report two cases of chiasmatic tuberculomas. They emphasize that diagnosis is still difficult despite CT scan if a picture of tuberculous meningitis is lacking. Surgical approach may be justified when diagnosis remains uncertain, especially as tuberculoma is sometimes responsible for recurrent meningitis.

Chiasmatic tuberculoma. 2 cases

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Acute polyradiculoneuropathy after amitriptyline overdose.

Melanotic meningioma. Report of a case and review of the literature.

Chiasmatic tuberculoma. 2 cases