What is the treatment for escitalopram (Lexapro) poisoning?

Treatment of Escitalopram Poisoning

The treatment for escitalopram poisoning requires immediate cardiac monitoring, supportive care, and consideration of gastrointestinal decontamination with activated charcoal in early presentations, with sodium bicarbonate administration for QRS prolongation and cardiovascular toxicity. 1

Initial Assessment and Stabilization

• Establish and maintain airway, breathing, and circulation as the first priority, following standard resuscitation protocols 2
• Contact a regional poison center (1-800-221-2222) for expert guidance on management 1
• Obtain an ECG immediately to assess for QRS prolongation and QTc interval prolongation, which may be delayed 1
• Initiate cardiac monitoring for a minimum of 24-48 hours due to the risk of delayed cardiotoxicity and arrhythmias 3

Specific Interventions

Gastrointestinal Decontamination

• Consider activated charcoal administration for patients who present early after escitalopram overdose 1
• Do not induce vomiting with syrup of ipecac or any other agent 4

Cardiovascular Management

• For QRS widening or prolongation (sodium channel blockade):
  • Administer sodium bicarbonate IV bolus (1-2 mEq/kg) followed by infusion if needed 5
  • Target serum pH of 7.45-7.55 to overcome sodium channel blockade 6
• For QTc prolongation:
  • Monitor closely for torsades de pointes 1
  • Consider magnesium sulfate 2g IV for QTc >500ms or if torsades de pointes develops 5
  • Correct electrolyte abnormalities, particularly potassium, magnesium, and calcium 5

Neurological Management

• For seizures:
  • Administer benzodiazepines as first-line treatment 6
  • Consider additional anticonvulsants if seizures persist 6

Management of Serotonin Syndrome

• Monitor for signs of serotonin syndrome (hyperthermia, neuromuscular abnormalities, autonomic instability) 7
• Provide aggressive cooling measures for hyperthermia 7
• Consider cyproheptadine (initial dose 12mg orally or via nasogastric tube, followed by 2mg every 2 hours until symptoms improve) for moderate to severe serotonin syndrome 7

Special Considerations

• Avoid flumazenil in mixed overdoses involving escitalopram and benzodiazepines due to the risk of seizures 2
• In cases of severe toxicity with hemodynamic instability refractory to conventional therapy, consider extracorporeal life support (ECLS) 6
• Prolonged cardiac monitoring is essential as cardiotoxicity may be delayed, with QTc prolongation potentially persisting for several days 3

Monitoring Parameters

• Continuous cardiac monitoring for at least 48 hours in significant overdoses 3
• Serial ECGs to track QRS and QTc intervals 5
• Core body temperature to detect hyperthermia 7
• Serum electrolytes, particularly potassium, magnesium, and calcium 5
• Mental status and neuromuscular examination for signs of serotonin syndrome 7

Pitfalls and Caveats

• The cardiotoxic effects of escitalopram may be delayed, so normal initial ECG does not rule out subsequent development of arrhythmias 1
• QRS widening in escitalopram overdose may respond to sodium bicarbonate, similar to tricyclic antidepressant overdose 5
• Patients with massive ingestions may develop life-threatening complications despite appropriate treatment 7
• Serotonin syndrome can develop rapidly and progress to severe hyperthermia and death if not recognized and treated promptly 7