How should a suspected quetiapine overdose be managed?

Management of Quetiapine Overdose

Quetiapine overdose requires immediate airway protection with endotracheal intubation for patients with Glasgow Coma Scale ≤8 or absent protective reflexes, followed by intensive supportive care with continuous cardiac monitoring in an ICU setting. 1, 2

Immediate Assessment and Airway Management

• Check for responsiveness and activate emergency response immediately without delay. 3
• Assess breathing and pulse for less than 10 seconds. 3
• Secure the airway promptly with bag-mask ventilation if respiratory depression is present; proceed immediately to endotracheal intubation if Glasgow Coma Scale is ≤8 or protective airway reflexes are absent. 4, 1, 2
• Quetiapine overdose can cause rapid progression to coma within hours, making early intubation for airway protection critical. 2
• Continue ventilatory support until spontaneous breathing returns, maintaining adequate oxygenation throughout. 4, 1

Gastrointestinal Decontamination

• Administer activated charcoal if the patient presents within 1-2 hours of ingestion and the airway is protected. 5, 2
• Consider gastric lavage only in massive overdoses (>10g) presenting very early, after airway protection is secured. 5

Cardiovascular Monitoring and Management

• Maintain continuous cardiac monitoring with serial electrocardiograms to detect QTc prolongation and conduction delays. 4, 5, 6, 2
• Monitor for persistent tachycardia, which is common and may last 2-3 days post-ingestion. 5, 2
• Administer intravenous saline for hypotension, which may occur alongside tachycardia. 5, 2
• QTc prolongation typically resolves by the second day without specific intervention beyond monitoring. 2

Intensive Care Unit Management

• All patients with quetiapine overdose requiring hospitalization should be admitted to an intensive care unit for close monitoring. 2
• Observe patients in a monitored setting until vital signs have normalized and the risk of recurrent toxicity is low. 4
• Monitor for hyperglycemia, which is a common complication of quetiapine overdose. 5, 6
• Watch for rare but serious complications including acute respiratory distress syndrome (ARDS), which may develop within 24 hours and require mechanical ventilation. 6
• Monitor for myoclonus and mental status changes as indicators of severe toxicity. 6

Duration of Monitoring

• Extended-release formulations require prolonged observation (36+ hours) due to delayed absorption and prolonged effects. 1
• Spontaneous breathing typically returns within 36 hours for massive overdoses of extended-release quetiapine. 1
• Mental status may improve rapidly within several hours for immediate-release formulations, but cardiovascular effects persist longer. 2

Advanced Interventions for Severe Cases

• In life-threatening overdoses with severe toxicity, hemoperfusion with CytoSorb sorbent in combination with continuous renal replacement therapy may accelerate quetiapine elimination. 7
• This extracorporeal approach should be considered only in massive overdoses with refractory hemodynamic instability or severe organ dysfunction. 7

Key Clinical Pitfalls to Avoid

• Never underestimate the potential for rapid deterioration to coma, even in patients who initially appear only lethargic. 1, 2
• Do not delay intubation in patients with declining mental status; quetiapine overdose can progress suddenly. 2
• The severity of quetiapine toxicity does not correlate reliably with serum concentration or reported ingested dose—clinical presentation guides management. 1
• Survival is possible even after massive overdoses (36g) with appropriate intensive supportive care. 1, 5