Table 3.

Case reports of tricyclic antidepressant intoxication resembling brain death (8)

Source	Age*/sex	Drug; dose	Duration of loss of brainstem reflexes	Neurologic exam	Failed brain death prerequisites	Neuro-imaging	EEG	Drug concentrations	Outcome
[28]	24/M	Doxepin; unknown	2–4 h	Pupils fixed, pinpoint. Absent corneal, oculocephalic, reflex and DTR. Internuclear ophthalmoplegia. Extensor plantar reflex. Flaccid extremities and no response to painful stimulation	Neuroimaging	Normal CT	NR	NR	Recovered brainstem reflexes; conscious; spontaneous respirations
[29]	40/F	Amoxapine; unknown	24 h	Pupils fixed at 4 mm. Absent corneal, oculocephalic, and ciliospinal reflex. No DTR. Decerebrate posturing of upper limbs to painful stimulation. Absent cold caloric response	Posturing to painful stimulation; Sodium 151 mmol/L; Potassium 5.9 mmol/L	NR	Burst suppression	NR	Recovery to baseline health
[30]	46/F	Amitriptyline; 9 g	24 h	Absent pupillary, corneal and oculocephalic reflex. No DTR. Flaccid extremities. No response to painful stimulation	Acidosis; Systolic BP < 100 mmHg	NR	NR	[Amitriptyline] 2350 ng/mL (therapeutic 75–225 ng/mL) [Phenobarbital] 3ug/mL (therapeutic 15–35 ug/ml)	Recovery to baseline health
[31]	39/F	Amitriptyline; unknown	48–72 h	Pupils 3 mm and unreactive. Absent corneal, oculocephalic, and gag reflex. Flaccid extremities	Neuroimaging	Normal CT	“Absence of well-developed alpha rhythm and low voltage beta activity”	[Amitriptyline] 1310 ng/mL [Nortriptyline] 39 ng/mL [Desmethylvenlafaxine] 140 ng/ml	Recovery to baseline health
[32]	52/M	Amitriptyline; 500 mg	24 h	“No detectable brainstem reflexes”	Neuroimaging	Normal CT	NR	[Amitriptyline] 2800 ng/mL (therapeutic 75–225 ng/mL) [Nortriptyline] 630 ng/mL [Nitrazepam] 0.62mcg/mL	Recovery to baseline health
[33]	18/M	Amitriptyline; 6 g	~ 48 h	“No brainstem reflexes were present”	Neuroimaging	Normal CT Normal CTA Normal MRI	Rhythmic activity at alpha frequency bilaterally, no response to painful stimulation, no seizure activity.	36 h after admission: [Amitriptyline] 1125 ng/mL [Nortriptyline] 568 ng/mL (no therapeutic range specified)	Recovery to baseline health
[34]	67/F	Amitriptyline; unknown	24 h	Absent Pupillary, corneal, oculocephalic and plantar reflex	Spontaneous respirations; Systolic BP < 100mgHg; Neuroimaging	Normal CT Normal CTA	NR	[Amitriptyline] > 730 ng/mL (therapeutic 100–300 ng/mL; toxic > 400 ng/mL); [Nortriptyline] 400 ng/mL	Extubated day 3, Transfer to floor on day 4 with confusion
[34]	28/M	Amitriptyline; unknown	“Several hours”	Absent Pupillary, corneal, oculocephalic and plantar reflex. No muscular tone	Spontaneous respirations; Neuroimaging	Normal CT Normal CTA	“Did not show any signs of epileptiform activity or encephalopathy”	Sample collected hospital day 3: [Amitriptyline] 330 ng/mL (therapeutic 100–300 ng/mL; toxic > 400 ng/mL) Bromazepam: 507 ng/mL (therapeutic 80–170 ng/mL; toxic > 250 ng/mL);	Extubated and transferred to ward on day 3

*Age in years; BP blood pressure, CT computerized tomography, CTA computerized tomography angiography, DTR deep tendon reflexes, EEG electroencephalogram, F female, M male, MRI magnetic resonance imaging, NR not reported