What is the treatment for a trazodone (antidepressant) overdose?

Treatment of Trazodone Overdose

The treatment of trazodone overdose requires immediate supportive care, ECG monitoring for QT prolongation, and management of potential complications including hypotension, respiratory depression, and seizures, as there is no specific antidote for trazodone toxicity. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC):

  • Establish and maintain airway patency
  • Provide supplemental oxygen and ventilatory support if needed
  • Monitor vital signs continuously

• ECG Monitoring:

  • Obtain immediate ECG to assess for QT prolongation and other cardiac abnormalities 2
  • Continue cardiac monitoring as QT prolongation may worsen over time 3
  • Watch for signs of Torsades de Pointes, which has been reported with trazodone overdose 2

Decontamination and Elimination

• Gastric Decontamination:
  • Activated charcoal administration if patient presents within 1 hour of ingestion and has intact airway reflexes 4
  • Standard dose: 1 g/kg of activated charcoal
  • Avoid induced emesis due to risk of rapid CNS depression

Specific Management

• Cardiovascular Support:

  • Administer IV fluids for hypotension (common in trazodone overdose) 5
  • For persistent hypotension, consider vasopressors
  • Monitor for and treat arrhythmias as indicated

• Seizure Management:

  • Benzodiazepines are first-line for seizure control 2
  • Flumazenil is contraindicated if co-ingestion of benzodiazepines is suspected 2
  • Adult dose of flumazenil: 0.2 mg, titrated up to 1 mg
  • Pediatric dose: 0.01 mg/kg 2

• Electrolyte Monitoring:

  • Check sodium levels as hyponatremia has been reported 6
  • Correct electrolyte abnormalities cautiously to prevent complications

Monitoring and Supportive Care

• Serial ECGs:

  • Monitor QTc interval every 1-2 hours until stable 3
  • QTc >500 ms warrants intensive monitoring due to increased risk of Torsades de Pointes

• Respiratory Monitoring:

  • Although trazodone appears to be less potent as a respiratory depressant compared to other antidepressants 4, respiratory function should still be closely monitored

• Level of Care:

  • ICU admission for patients with:
    • QTc prolongation >500 ms
    • Hemodynamic instability
    • Respiratory depression
    • Seizures
    • Large ingestions (>2 grams)

Special Considerations

• Co-ingestions:

  • Death from trazodone overdose is more common when combined with other CNS depressants (alcohol, benzodiazepines, barbiturates) 1, 7
  • More aggressive management may be needed with co-ingestions

• High-Risk Patients:

  • Patients with pre-existing cardiac disease, seizure disorders, or respiratory compromise require closer monitoring 7
  • Elderly patients may be more susceptible to adverse effects

Pitfalls and Caveats

• Delayed Toxicity:

  • QT prolongation and hypotension may develop or worsen hours after initial presentation 3
  • Minimum 6-hour observation period recommended even for asymptomatic patients

• Misdiagnosis:

  • Trazodone overdose may be mistaken for other serotonergic agents but has distinct toxicity profile
  • Unlike tricyclic antidepressants, anticholinergic effects are less prominent 5

• Underestimation of Severity:

  • While historically considered to have limited toxicity when taken alone 7, recent case reports document serious complications including fatal cerebral edema 6 and significant QT prolongation 3

By following this approach, clinicians can effectively manage trazodone overdose and minimize the risk of serious complications or death.