What is the management approach for an escitalopram (citalopram) overdose?

Management of Escitalopram Overdose

Immediate management of escitalopram overdose should focus on cardiac monitoring, supportive care, and specific interventions to prevent life-threatening complications, particularly QT prolongation and torsade de pointes. 1

Initial Assessment and Stabilization

• Secure airway, breathing, and circulation following standard resuscitation protocols 2
• Obtain immediate 12-lead ECG to assess for QT/QTc prolongation, QRS widening, and other cardiac abnormalities 3
• Consider gastrointestinal decontamination with activated charcoal if presentation is within 1-2 hours of ingestion 1
• Contact poison control center (1-800-221-2222) for case-specific management recommendations 1

Cardiac Monitoring and Management

• Initiate continuous cardiac monitoring for at least 24-48 hours post-ingestion due to risk of delayed arrhythmias 3
• Monitor QTc interval closely - values >500ms significantly increase risk of torsade de pointes 4
• For QRS widening (sodium channel blockade), administer sodium bicarbonate:
  • Initial dose: 1-2 mEq/kg IV bolus 5
  • Consider sodium bicarbonate infusion for persistent QRS widening 5
• For QTc prolongation:
  • Administer IV magnesium sulfate 2g over 10 minutes 6
  • Correct any electrolyte abnormalities, particularly potassium, magnesium, and calcium 7
  • Avoid other QT-prolonging medications 7

Management of Serotonin Syndrome

• Monitor for signs of serotonin syndrome: hyperthermia, increased muscle tone, hyperreflexia, clonus, autonomic instability 4
• If serotonin syndrome is suspected:
  • Administer cyproheptadine (initial dose 4-8 mg orally, may repeat hourly to maximum 32 mg/day) 2
  • Provide aggressive cooling measures for hyperthermia 2
  • Consider benzodiazepines for agitation and muscle rigidity 7

Supportive Care

• Maintain hydration with IV fluids 2
• Monitor vital signs frequently, with special attention to temperature (hyperthermia indicates possible serotonin syndrome) 2
• Treat seizures if they occur with benzodiazepines 1
• For hemodynamic instability:
  • Administer IV fluids for hypotension 6
  • Consider vasopressors for persistent hypotension unresponsive to fluids 2

Monitoring Duration and Discharge Criteria

• Continue cardiac monitoring until:
  • QTc interval has normalized or returned to baseline 3
  • At least 24-48 hours have passed since ingestion 3
  • No evidence of serotonin syndrome or other toxicity 4
• Psychiatric evaluation should be completed prior to discharge for intentional overdoses 3

Special Considerations

• Higher risk of complications with:
  • Doses exceeding 600mg 2
  • Co-ingestion of other serotonergic or QT-prolonging medications 7
  • Pre-existing cardiac conditions or electrolyte abnormalities 7
  • Delayed presentation after overdose 2

Common Pitfalls to Avoid

• Underestimating the need for prolonged cardiac monitoring - QT prolongation may persist for 2-4 days 3
• Failing to recognize sodium channel blockade (QRS widening) which may respond to sodium bicarbonate 5
• Missing signs of serotonin syndrome which can be life-threatening if not treated promptly 2
• Discharging patients too early before cardiac effects have fully resolved 3

Remember that while most patients recover from escitalopram overdose with supportive care, severe toxicity can occur with high-dose ingestions, potentially leading to fatal outcomes if not managed appropriately 2.