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Toxicity, Benzodiazepine: Follow-up

Author: Robin Mantooth, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Norman Regional Health System; Adjunct Clinical Assistant Professor, Family Medicine, Oklahoma State University; Consulting Staff, Department of Emergency Medicine, Integris Southwest Medical Center; Consulting Staff, Department of Emergency Medicine, Oklahoma University Medical Center; Consulting Staff, Department of Emergency Medicine, Integris Canadian Valley Health Center; Consulting Staff, Department of Emergency Medicine, Saint Anthony Hospital; Consulting Staff, Department of Emergency Medicine, Commanche County Medical Center; Consulting Staff, Department of Emergency Medicine, Claremore Medical Center
Contributor Information and Disclosures

Updated: Jan 28, 2010

Follow-up

Further Inpatient Care

  • Admit patients with hemodynamic instability, coma, or respiratory depression to the ICU.
  • Watch for signs of withdrawal in patients who have been taking benzodiazepines (BZDs) chronically before overdose.

Further Outpatient Care

  • Patients may be discharged if they remain asymptomatic at least 6 hours post ingestion. Those with mild toxicity may be observed in the emergency department until they recover. Patients with intentional overdoses have to be evaluated by a psychiatrist.

Transfer

  • Transfer patients who may require more advanced care than is available in either the ED or inpatient setting.

Complications

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Unmasking an underlying disorder, specifically seizures, with indiscriminate use of flumazenil
  • Administration of full dose of naloxone (0.4 mg or more) and precipitation of opioid withdrawal in patients with mixed overdose resulting in aspiration of gastric content
  • Administration of charcoal in patients with unprotected airway
  • Failure to anticipate withdrawal in a patient with chronic benzodiazepine (BZD) use
  • Failure to consider the possibility of co-ingestant use or secondary causes of treatable altered mental status (eg, hypoglycemia, meningitis)
 


More on Toxicity, Benzodiazepine

Overview: Toxicity, Benzodiazepine
Differential Diagnoses & Workup: Toxicity, Benzodiazepine
Treatment & Medication: Toxicity, Benzodiazepine
Follow-up: Toxicity, Benzodiazepine
References
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References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila). Dec 2009;47(10):911-1084. [Medline]. [Full Text].

  2. Serfaty M, Masterton G. Fatal poisonings attributed to benzodiazepines in Britain during the 1980s. Br J Psychiatry. Sep 1993;163:386-93. [Medline].

  3. [Guideline] Kleber HD, Weiss RD, Anton RF, et al. Treatment of patients with substance use disorders, second edition. American Psychiatric Association. Am J Psychiatry. Aug 2006;163(8 Suppl):5-82. [Medline]. [Full Text].

  4. [Guideline] National Collaborating Centre for Mental Health. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE). 2004;199. [Full Text].

  5. Bosse GM. Benzodiazepines. In: Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:759-61.

  6. Buckley NA, Dawson AH, Whyte IM, O'Connell DL. Relative toxicity of benzodiazepines in overdose. BMJ. Jan 28 1995;310(6974):219-21. [Medline].

  7. Cairns C. Benzodiazepine overdose and withdrawal. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. Mosby-Year Book; 1992:2684-9.

  8. Drummer OH, Syrjanen ML, Cordner SM. Deaths involving the benzodiazepine flunitrazepam. Am J Forensic Med Pathol. Sep 1993;14(3):238-43. [Medline].

  9. Hoffman RS, Wipfler MG, Maddaloni MA, Weisman RS. Has the New York State triplicate benzodiazepine prescription regulation influenced sedative-hypnotic overdoses?. N Y State J Med. Oct 1991;91(10):436-9. [Medline].

  10. Longmire AW, Seger DL. Topics in clinical pharmacology: flumazenil, a benzodiazepine antagonist. Am J Med Sci. Jul 1993;306(1):49-52. [Medline].

  11. Mullins ME. First-degree atrioventricular block in alprazolam overdose reversed by flumazenil. J Pharm Pharmacol. Mar 1999;51(3):367-70. [Medline].

  12. Verghese J, Merino J. Temazepam overdose associated with bullous eruptions. Acad Emerg Med. Oct 1999;6(10):1071. [Medline].

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Further Reading

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Keywords

BZD toxicity, sedative-hypnotic toxicity, benzodiazepine toxicity, benzodiazepine treatment, flumazenil, benzodiazepine exposure, BZD exposure, seizure control, anxiety, alcohol withdrawal, alprazolam, flunitrazepam, chlordiazepoxide, diazepam, triazolam, temazepam, flurazepam, bromazepam, clorazepate, oxazepam, nitrazepam, alprazolam, lormetazepam, lorazepam, benzodiazepine overdose

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Contributor Information and Disclosures

Author

Robin Mantooth, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Norman Regional Health System; Adjunct Clinical Assistant Professor, Family Medicine, Oklahoma State University; Consulting Staff, Department of Emergency Medicine, Integris Southwest Medical Center; Consulting Staff, Department of Emergency Medicine, Oklahoma University Medical Center; Consulting Staff, Department of Emergency Medicine, Integris Canadian Valley Health Center; Consulting Staff, Department of Emergency Medicine, Saint Anthony Hospital; Consulting Staff, Department of Emergency Medicine, Commanche County Medical Center; Consulting Staff, Department of Emergency Medicine, Claremore Medical Center
Robin Mantooth, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Medical Editor

David C Lee, MD, Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School
David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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