My short and sweet version goes like this: it sounds like your management of the pt was appropriate. I would always recommend that you call your local poison control for tips on management of overdoses as they can really help. If they wouldnt drink the charcoal for me? I would skip it, and most definitely would never sedate or intubate them just so I could give them charcoal. His tachycardia could have been coming from the tricyclic or it could have just been from his agitation. Sedation with a benzo again is appropriate. Was he acidotic? or was his qrs prolonged as to why you were giving so much bicarb? Now for my long part
I will be the first to admit that taking care of drug overdoses can be difficult and tricky. It would seem that gastric lavage would be an obvious intervention just like using ipecac to make a kid throw up. However despite research gastric lavage hasnt really been shown to be effective. Then you have to look at the fact that gastric lavage can be harmful so why have an intervention that is not effective and may actually cause harm?
I will post an abstract from the Clinical toxicologist website on a position statement:
"Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnormalities,
and aspiration pneumonitis. Contraindications include loss of protective
airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition. A review of the 1997 Gastric Lavage Position Statement revealed no new evidence that would require a revision of the conclusions of the Statement."
Similarly activated charcoal has not really been shown to improve pt outcomes but again carries risk of aspiration especially in an obtunded pt. The current thinking is pretty much this, activated charcoal may provide some benefit if given within an hour of ingestion however again you need to think of the risks. If a person is alert and willing to drink it, (and it is something charcoal will adsorb) then it is probably not going to hurt to give it. If the patient is lethargic, or you have to use a NG tube to give it, I would hesitate and directly consult with your poison control.
I think a lot of people get hung up on "antidotes" when really with a drug overdose, you pretty much just have to treat what you see ie hypotension, arrythmias, etc.