A 23 years old women presented to ED 1 hour after ingesting unknown amount with the below medication in a sucidal attempt.

She is complaning of inability to pass urine .Clinically she is concious and alert
Vitals within normal.
Q1.How do you explain her symptom and how to predict her toxicity?
Q2.How you will manage her?
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After an overdose of a TCA, symptoms typically begin within
1 to 2 hours. With smaller ingested amounts, symptoms may be
minimal and resolve quickly; patients who take large amounts
may deteriorate rapidly soon after ingestion.
Severely poisoned patients typically have symptoms within 6 hours of an overdose.
Early cyclic antidepressant toxicity (within the first 2 hours) is
primarily characterized by anticholinergic effects.
These findings include:
- dry mucosal membranes,
-urinary retention, and
- hot, dry skin.
Despite having potent antimuscarinic properties, the pupils
are often small due to alpha effects
Significant sodium channel blockade is associated with widening of the QRS interval. The degree of QRS widening is prognostic.
* A QRS wider than 100 msec is associated with seizures,
* QRS complex wider than 160 msec is associated with ventricular dysrhythmias.
With severe poisoning, the combined effects of the TCA on
various receptors and ion channels lead to depressed level of
consciousness, seizures, hypotension, and wide-complex cardiac
arrhythmias.
Disposition : Patient should be observe for at least 6 hours. If the heart rate has not exceeded 100/minute , ECG intervals are normal, level of consciousness is normal, and no seizures have developed within 6 hours of a TCA overdose, it is unlikely that toxicity will occur.
The patient can be medically cleared from the emergency department for
psychiatric evaluation and disposition if needed.
Patients with signs of cyclic antidepressant cardiotoxicity, seizures, or coma
should be admitted to ICU.
References:
1- Goldfrank’s of Toxicologic Emergencies , 11th edition
A1. Amitriptyline is a TCA.
Toxicity can occur with a dose as low as 15 mg/kg.
Peak TCA serum level ranges from 2-12 hrs; symptoms typically occurs within 2 hrs from ingestion.
TCA toxicity has CVS, CNS and Peripheral autonomic system manifestations, as in our patient (anticholinergic SE: urinary retention)
A2. After stabilizing the patient (airway protection, ventilation and oxygenation, intravenous fluids, cardiac monitoring, and performing electrocardiography (ECG) )
Patient should be kept on monitors. Observe for any ECG changes (QRS: >100ms associated with seizures, QRS: >160ms associated with ventricular arrhythmias) and altered level of consciousness, specially in the 1st 6-8 hrs.(as they are the most sensitive predictors for TCA Toxicity )
gastric decontamination with activated charcoal is not advised due to risk of aspiration. Can be given in pts who ingested >10-15 mg/kg after intubation 1-2 hrs after ingestion.
Pt. Can only be discharge home if remains asymptomatic (no ECG changes) in the 1st 6-8 hrs after Psychiatry consultation:
(suicidal ideation)evaluation for admission.