Is there a role for hemoperfusion/hemodialysis as a treatment option in severe tricyclic antidepressant intoxication?

Objective: Suicidal self-poisoning with tricyclic antidepressants like doxe pin is a major therapeutic problem in emergency medicine with a high fatali ty rate. Deaths are mainly caused by cardiotoxicity with arrhythmias, intra ventricular conduction disturbances and myocardial depression. For treatmen t alkalinization and hypertonic saline are recommended. The role of extraco rporeal treatment procedures is not clear. The possible benefit of hemoperf usion/hemodialysis is discussed in a case report with respect to the publis hed literature. Case report: After ingestion of an amount of at least 5000 mg doxepin a 37- year-old man with endogenous depression developed cardiac arrest After prec linical resuscitation with prolonged external cardiac massage, he was admit ted to the intensive care unit with persistently Severe hypotension and wid e QRS complexes (230-260 ms). Despite fluid load, alkalinization, hypertoni c saline and high-dose vasoactive substances the patient's condition did no t improve. Hemoperfusion over hemoresin combined with hemodialysis led to a n impressive clinical improvement with shortening of QRS duration (from 230 to 120 ms) and hemodynamic stabilization. The patient fully recovered with out neurologic deficits. Conclusion: We report a successful treatment with hemoperfusion over hemore sin and hemodialysis in a patient with life-threatening doxepin poisoning i ntractable with the generally recommended treatment. in such acute TCA into xication with severe cardiotoxicity, hemoperfusion/hemodialysis should be c onsidered a potential treatment option, as the "toxicokinetics" of drugs ma y totally differ from their usual pharmacokinetic behaviour. Experimental a nd clinical studies are needed to clarify the toxicokinetics of TCA in orde r to improve the therapeutic approach.