Benzodiazepine toxicity: Difference between revisions

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==Clinical Features==
==Clinical Features==
#Somnolence, slurred speech, ataxia (similar to ETOH intoxication)
*Somnolence, slurred speech, ataxia (similar to [[ETOH intoxication]])
#Paradoxical reaction (more common in hyperactive children, psychiatric patients)
*Paradoxical reaction (more common in hyperactive children, psychiatric patients)
#Hypotension
*[[Hypotension]]
#Respiratory depression
*Respiratory depression


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
*[[Urine toxicology screen]]
**Most [[benzodiazepine]] screens look for oxazepam, which is a metabolite of [[diazepam]] and [[chlordiazepoxide]]. Therefore, [[lorazepam]], [[alprazolam]], and [[clonazepam]] are commonly missed.
**True positives: Oxazepam, [[temazepam]], [[diazepam]], [[alprazolam]], [[triazolam]]
**False negatives: [[Lorazepam]], [[clonazepam]], [[midazolam]]


==Management==
==Management==
#GI decontamination
*[[GI decontamination]]
##[[Activated Charcoal]] x1
**[[Activated Charcoal]] x1
#Mechanical ventilation if necessary
*[[Mechanical ventilation]] if necessary
#Flumazenil
 
##Controversial
===[[Flumazenil]]===
###May prevent need for mechanical ventilation; may precipitate benzo-withdrawal seizure
*Controversial
##Indication:
**May prevent need for [[mechanical ventilation]]; may precipitate benzo-withdrawal [[seizure]]
###Consider (though controversial) for coma reversal
*Indication:
##Contraindications:
**Consider (though controversial) for coma reversal
###Suspected or known physical dependence on benzodiazepines
*Contraindications:
###Suspected TCA overdose
**Suspected or known physical dependence on benzodiazepines
###Co-ingestion of seizure-inducing agents
**Suspected TCA overdose
###Known [[seizure]] disorder
**Co-ingestion of seizure-inducing agents
###Suspected increased intracranial pressure
**Known [[seizure]] disorder
##Dosing
**Suspected increased intracranial pressure
###0.2mg IV; may repeat q1min (max dose 3mg)
*Dosing
##Flumazenil-Induced Seizure
**0.2mg IV; may repeat q1min (max dose 3mg)
###Treat with phenobarbital or propofol; benzos will not work
*Flumazenil-Induced Seizure
#Withdrawal
**Treat with [[phenobarbital]] or [[propofol]]; benzodiazepines will not work
##High risk - GABA activity withdrawn
###CNS excitation:agitation, tremor, hallucinations, seizures
###Autonomic Instability: tachycardia, hypertension, hyperthermia, diaphoresis


==Disposition==
==Disposition==
*Consider discharge after 6hr obs
*Consider discharge after 6hr observation


==See Also==
==See Also==
*[[Sedative/Hypnotic]]
*[[Sedative/Hypnotic]]
*[[Benzodiazepines]]
*[[Benzodiazepines]]
*[[Benzodiazepine withdrawal]]


==References==
==References==

Revision as of 05:11, 12 March 2017

Background

  • Isolated benzodiazepine overdose has low morbidity/mortality
    • Coingestion or parenteral administration accounts for vast majority of deaths

Clinical Features

  • Somnolence, slurred speech, ataxia (similar to ETOH intoxication)
  • Paradoxical reaction (more common in hyperactive children, psychiatric patients)
  • Hypotension
  • Respiratory depression

Differential Diagnosis

Sedative/hypnotic toxicity

Evaluation

Management

Flumazenil

  • Controversial
  • Indication:
    • Consider (though controversial) for coma reversal
  • Contraindications:
    • Suspected or known physical dependence on benzodiazepines
    • Suspected TCA overdose
    • Co-ingestion of seizure-inducing agents
    • Known seizure disorder
    • Suspected increased intracranial pressure
  • Dosing
    • 0.2mg IV; may repeat q1min (max dose 3mg)
  • Flumazenil-Induced Seizure

Disposition

  • Consider discharge after 6hr observation

See Also

References