Sodium Bicarbonate in TCA Poisoning

Mechanisms of Action and Clinical Indications

Sodium bicarbonate achieves therapeutic benefit through two synergistic mechanisms: sodium loading and alkalinization, which overcome sodium channel blockade, improve cardiac conduction, and reduce cardiotoxicity, as recommended by the American Heart Association 1, 2
The American College of Cardiology recommends administering sodium bicarbonate for TCA poisoning when ventricular dysrhythmias are present, with a strength of evidence of high 1
Terminal rightward axis deviation >120 degrees in lead aVR is an indication for sodium bicarbonate administration, according to the American Heart Association 1

The American Heart Association recommends an initial bolus dose of 1-2 mEq/kg (1-2 mL/kg of 8.4% solution) IV for adults, with a strength of evidence of moderate 1, 3
For children, the recommended dose is 1-2 mEq/kg IV given slowly, as suggested by the American Academy of Pediatrics 3
Repeat boluses may be necessary until clinical stability is achieved, with a strength of evidence of low 2

The American Heart Association recommends achieving and maintaining a serum pH of 7.45-7.55, with a strength of evidence of high 2, 4
Serum sodium levels should be maintained at <150-155 mEq/L to avoid hypernatremia, as recommended by the American Heart Association 2, 4
Continuous ECG monitoring is necessary for QRS duration and dysrhythmias, with a strength of evidence of moderate 2

The American Heart Association recommends considering VA-ECMO for refractory cardiogenic shock, with a Class 2a recommendation and a strength of evidence of moderate 1, 5
Lidocaine may be used as second-line therapy for refractory ventricular dysrhythmias after sodium bicarbonate, with a strength of evidence of low 2