What is the recommended management for TCA overdose with a long QRS interval?

In cases of tricyclic antidepressant (TCA) overdose characterized by a prolonged QRS interval, sodium bicarbonate is the appropriate management. The mechanism behind using sodium bicarbonate is its ability to alkalinize the blood, which helps to reduce the cardiotoxic effects of TCAs. TCA overdose can lead to sodium channel blockade, resulting in a prolonged QRS and an increased risk of arrhythmias. By alkalinizing the serum, sodium bicarbonate facilitates the binding of the drug to proteins and may help to restore more normal cardiac conduction.

Additionally, the administration of sodium bicarbonate can improve hemodynamics by increasing extracellular sodium concentrations. This can help counteract the sodium-channel blockade caused by TCAs and is particularly effective in addressing QRS widening, thereby reducing the risk for life-threatening arrhythmias.

While activated charcoal could be used for gastrointestinal decontamination, it is not as specific or directly beneficial in addressing the complications of TCA overdose, especially once QRS widening has occurred. Intravenous fluids may be supportive but do not target the specific cardiotoxic effects of the TCA. Antidepressants would not be a suitable management choice in this scenario and would not counteract the overdose effects.

Thus, sodium bicarbonate