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

OBJECTIVE: Suicidal self-poisoning with tricyclic antidepressants like doxepin is a major therapeutic problem in emergency medicine with a high fatality rate. Deaths are mainly caused by cardiotoxicity with arrhythmias, intraventricular conduction disturbances and myocardial depression. For treatment, alkalinization and hypertonic saline are recommended. The role of extracorporeal, treatment procedures is not clear. The possible benefit of hemoperfusion/hemodialysis is discussed in a case report with respect to the published 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 preclinical resuscitation with prolonged external cardiac massage, he was admitted to the intensive care unit with persistently severe hypotension and wide QRS complexes (230-260 ms). Despite fluid load, alkalinization, hypertonic saline and high-dose vasoactive substances the patient's condition did not improve. Hemoperfusion over hemoresin combined with hemodialysis led to an impressive clinical improvement with shortening of QRS duration (from 230 to 120 ms) and hemodynamic stabilization. The patient fully recovered without neurologic deficits.
CONCLUSION: We report a successful treatment with hemoperfusion over hemoresin and hemodialysis in a patient with life-threatening doxepin poisoning intractable with the generally recommended treatment. In such acute TCA intoxication with severe cardiotoxicity, hemoperfusion/hemodialysis should be considered a potential treatment option, as the "toxicokinetics" of drugs may totally differ from their usual pharmacokinetic behaviour. Experimental and clinical studies are needed to clarify the toxicokinetics of TCA in order to improve the therapeutic approach.