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.
Why TCAs Cause Multi-System Toxicity
- Tricyclic antidepressants are pharmacologically “dirty” and affect many receptors beyond monoamine reuptake.
- Their multi-receptor actions explain anticholinergic signs, hypotension, sodium-channel cardiac toxicity, seizures, and QT effects.
Immediate Workup And First-Line Actions
- Obtain glucose and an ECG immediately and reassess frequently; QRS duration predicts severity.
- If QRS is prolonged, secure airway, consider charcoal/lavage if early, and give sodium bicarbonate.