Bicarb is alkalotic and TCA's are acidotic
When comparing the pH levels from a chemical standpoint alone this may have some validity however the purpose of pushing bicarb for a TCA OD would be to specifically treat the wide QRS complex if it is seen on the ECG. I am seeing a lot of tangents on this post but if we get back to the basics, H's & T's from ACLS we will realize two very basic things when looking at this symptomatically:
First, a hallmark of Hyperkalemia is the widening of the QRS complex which is the same symptom in our case of the TCA OD here, either way bicarb is used to treat.
Second, Acidosis or (Hydrogen Ion from our mnemonic) can be reversed with bicarb. In our case we are not so concerned about the acidosis because a TCA OD will cause the wide-QRS which should be reversed by bicarb. Absorbtion secondary to protein binding or the nature of the pH animal is something else altogether.
Next, what about as I mentioned earlier, if acute and the patient is not overly symptomatic (yet) the administration of activated charcoal will work as part of the treatment plan, the caveat is a one hour time limit I believe, also I know as a fact it wont work if the OD occurred over a "long" duration since absorption has already set in.
Finally, we see and hear all the time to treat the patient, not the numbers. So the real question, in my humble opinion would be to see what the symptoms are and to treat them because as I mentioned earlier the patient should be in the clear within 24 hours and can be downgraded from the ICU after 12 hours (strictly speaking in terms of Serotonin Syndrome) so as long as the patient is maintained properly the drug will work its way out of the body, the key is management of the overall patient to see them through that first day. Bottom line there is not much to do other than treat the symptoms in the pre-hospital setting.
One interesting segue about serotonin syndrome is that if the BP falls too low you will need a direct acting drug such as epinephrine to bring it back up, I do not believe that dopamine or dobutamine will work in this case. Someone please chime in if I am wrong about this.
I hope this does not sound too pretentious of me but its bugging me that so many people were wanting to slam bicarb... I feel getting back to the basics answers most questions including this one.
