PedsCrit Tricyclic Antidepressant Ingestions with Dr. Josh Nogar
Nov 10, 2025
Dr. Joshua Nogar, an emergency physician and board-certified medical toxicologist, shares his expertise on managing tricyclic antidepressant toxications. He discusses the complex pharmacology of TCAs and the importance of early recognition of toxicity. Key insights include the significance of QRS duration in predicting cardiac issues, strategies for airway management, and the use of sodium bicarbonate therapy. Dr. Nogar also delves into advanced treatment options like lipid emulsion therapy and emphasizes the necessity for vigilant reassessment in cases of suspected overdose.
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Building A Large MedTox Consult Service
- Northwell Health's toxicology service grew from a few hospitals to covering a 28-hospital system.
- Dr. Josh Nogar describes building a virtual consult service and bedside coverage across multiple sites.
QRS As A Prognostic Indicator
- QRS >100 ms raises seizure risk; QRS >160 ms predicts ventricular dysrhythmia.
- Seizures cause acidosis, which increases TCA binding to sodium channels and rapidly worsens cardiac toxicity.
Intubation Enables Decontamination
- Intubate early for airway protection in patients with altered mental status or rising QRS.
- After RSI, perform orogastric lavage (if within ~1–2 hours) then leave activated charcoal in place.