Citalopram overdose: late presentation of torsades de pointes (TdP) with cardiac arrest.
BACKGROUND
Citalopram overdose may produce bradycardia, QT prolongation, and torsades de pointes (TdP). A cardiotoxic metabolite may be responsible for the delayed onset of cardiotoxicity. Although some authorities recommend a minimum of 24 hours of observation following citalopram overdose, a recent analysis suggested that dysrhythmias rarely occur beyond 13 hours post-ingestion. We present a case of citalopram overdose with a substantially delayed onset of cardiac toxicity.


METHODS
A 36-year-old woman complained of shakiness, numbness in the arms, and palpitations that began approximately 32 hours after ingesting 50 (20-mg) tablets of citalopram. Her initial vital signs were: blood pressure, 84/44 mmHg; pulse, 102-150/minute; respirations, 17/min; temperature, 99.3 degrees F (37.3 degrees C). Her initial ECG showed sinus rhythm with a prolonged corrected QT interval (572 msec) with paroxysmal, self-limited runs of wide-complex tachycardia that appeared multifocal in nature. Approximately 20 minutes after presentation, she experienced self-terminating TdP, with transient hypotension and loss of consciousness. Her serum citalopram concentration (33 hours post-ingestion) was 477 ng/mL (therapeutic: 40-110 ng/mL); desmethylcitalopram concentration was 123.2 ng/mL (therapeutic: 14-40 ng/mL). She was treated with magnesium and lidocaine, and her corrected QT interval remained abnormal for 24 hours after presentation.


CONCLUSIONS
Citalopram overdose can produce life-threatening cardiac toxicity with a clinical onset that may be delayed beyond a routine observation period of 6 hours. Once the QT interval is prolonged, it seems prudent to prolong the observation period.
Yale University School of Medicine, New Haven, CT, USA.
Asim F
AF
Tarabar
Robert S
RS
Hoffman
Lewis
L
Nelson
D000328:Adult; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D018687:Antidepressive Agents, Second-Generation / Q000097:blood / Q000506:poisoning*; D015283:Citalopram / Q000097:blood / Q000506:poisoning*; D062787:Drug Overdose; D004562:Electrocardiography; D005260:Female; D006323:Heart Arrest / Q000139:chemically induced* / Q000188:drug therapy / Q000503:physiopathology; D006801:Humans; D008012:Lidocaine / Q000627:therapeutic use; D008278:Magnesium Sulfate / Q000627:therapeutic use; D017367:Selective Serotonin Reuptake Inhibitors / Q000097:blood / Q000506:poisoning*; D013406:Suicide, Attempted; D013997:Time Factors; D016171:Torsades de Pointes / Q000139:chemically induced* / Q000188:drug therapy / Q000503:physiopathology; D016896:Treatment Outcome
D000889:Anti-Arrhythmia Agents; D018687:Antidepressive Agents, Second-Generation; D015283:Citalopram; D008012:Lidocaine; D008278:Magnesium Sulfate; D017367:Selective Serotonin Reuptake Inhibitors