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Tricyclic antidepressant (TCA) overdose is one of the most common causes of serious drug poisoning in children. Amitriptyline is a major TCA drug that is used widely. Tricyclic antidepressant intoxications are very important because of their severe adverse effects and probable fatal outcomes. It may cause cardiovascular, respiratory and neurological side effects. Poisoning results in hypotension, cardiac dysrhythmia, depression of the central nervous system (CNS) and seizures. The most common effects on the central nervous system are agitation, lethargy, seizures, and coma. Cardiovascular toxicities manifest itself especially with electrocardiographic (ECG) abnormalities, arrhythmias, and refractory hypotension and they are the leading cause of fatal outcome.  Treatments in TCA overdose are mainly conservative including gastric lavage, activated charcoal and vasopressors for hypotension, sodium bicarbonate for dysrhythmias, and benzodiazepines for seizures. Magnesium sulfate (MgSO4) also has an effective role in the treatment of fatal cardiac arrhythmias occurring in high-dose amitriptyline intoxication. Intravenous lipid emulsions have been increasingly studied as antidotes to reverse acute, life-threatening drug toxicity. Unpredictable and poor results with hemoperfusion (HP) and hemodialysis (HD) should be expected, as the drug binds rapidly to tissues and has a large volume of distribution. But beside it, in the last few years, HP has been successfully used in severe TCA overdose, especially in patients with persistent respiratory, cardiac, and neurologic symptoms. Besides all these, recently, plasma exchange, have been increasingly used. A reduction of plasma levels by 63% after plasmapheresis in TCA poisoning has been reported. Here, we report a successful treatment of plasma exchange 3 year patient with amitriptyline overdose who had arrhythmias and seizures that wasn't respond all to conservative therapies.

Treatment of Pediatric Life Threatening Amitriptilin Intoxication with Plasma Exchange