Sedative-Hypnotic Toxicity Clinical Presentation
- Author: Jeffrey S Cooper, MD, FAAEM, FACEP; Chief Editor: Asim Tarabar, MD more...
History
The history should include the following information:
- Agents ingested
- Amount of ingestion
- Time of ingestion
- Cause and/or reason for ingestion (eg, accidental, intentional, suicide attempt, recreational)
- Whether ingestion is acute or chronic
- Past medical history and history of drug abuse
- Circumstances surrounding the overdose
Physical
Focus the physical examination on vital signs and neurologic and cardiopulmonary status.
General
Mild toxicity resembles ethanol intoxication. Severe respiratory depression is more likely to occur when the sedative-hypnotic is ingested with other CNS depressants.
Flexor or extensor posturing can be present in coma resulting from sedative drug ingestion. It does not imply structural damage in this setting.
Barbiturates
Mild intoxication is characterized by ataxia, incoordination, nystagmus, slurred speech, and altered level of consciousness.
Moderate poisoning leads to respiratory depression and hyporeflexia.
Severe poisoning leads to flaccid areflexic coma, apnea, and hypotension.
Generally, 10 times the hypnotic dose produces severe toxicity.
Occasionally, hyperreflexia, rigidity, clonus, and Babinski signs are present.
Miosis is common, but mydriasis may be present with certain agents.
The nonbarbiturates, such as methyprylon and glutethimide, more commonly present with mydriasis.
Hypotension is usually secondary to vasodilation and negative cardiac inotropic effects.
Complications include the following:
- Noncardiogenic pulmonary edema
- Hypothermia
- Delayed gastric emptying (therefore, late lavage and multiple charcoal is effective)
- Skin lesions (clear vesicles and bullae on an erythematous base at contact surfaces) occur in 6% of ingestions and in approximately 50% of lethal ingestions.
Methaqualone (Quaalude)
- Resembles barbiturate poisoning
- Has more pronounced motor problems (eg, ataxia) and is known as wallbanger because of this phenomenon
- Can lead to severe muscular hypertonicity and seizures
Glutethimide (Doriden)
- Loss of brainstem reflexes
- Flaccidity
- Anticholinergic effects
- Delayed gastric emptying
- May cause hyperthermia or heatstroke
Ethchlorvynol (Placidyl)
- Pungent odor of breath and gastric contents
- Prolonged coma (up to 2 wk)
- Acute respiratory distress syndrome (ARDS) predominates in IV use
Chloral hydrate
- Synergistic with alcohol (knockout drops, Mickey Finn)
- Cerebellar incoordination
- Severe gastritis and GI bleed
- Multiple dermatologic effects, including purpura, bullae, urticaria, and erythema multiforme (EM)
- CNS depression with cardiopulmonary collapse
- Associated with hepatitis, gastritis, proteinuria, and dysrhythmias
- Odor of pears
- Radiopaque
Imidazopyridine
- Sleepwalking or other complex bizarre behaviors
- Chromaturia (blue-green urine discoloration) has been reported with zaleplon (Sonata) overdose.
- Prolonged coma and respiratory failure
Meprobamate
- CNS and respiratory depression
- Hypotension (common)
GHB and GBL
Mild intoxication includes the following:
- Slurred speech
- Disinhibition
- Euphoria
- Mild lethargy
- Moderate intoxication
- CNS and mild respiratory depression
- Agitation when stimulated
- Myoclonus
Severe intoxication includes the following:
- Unresponsive coma
- Miosis
- Bradycardia
- Mild hypotension
- Seizures
- Respiratory depression and apnea
After ingestion, the onset of effects occurs within 15 minutes and peaks in 1.5-2 hours. Elimination of GHB is rapid (elimination half-life 1-2 h). The duration of clinical effects is 2-8 hours.
Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-1178. [Medline].
Barnett R, Grace M, Boothe P, et al. Flumazenil in drug overdose: randomized, placebo-controlled study to assess cost effectiveness. Crit Care Med. Jan 1999;27(1):78-81. [Medline].
Bledsoe BE. No more coma cocktails. Using science to dispel myths & improve patient care. JEMS. Nov 2002;27(11):54-60. [Medline].
Clark RF, Sage TA, Tunget C, Manoguerra AS. Delayed onset lorazepam poisoning successfully reversed by flumazenil in a child. Case report and review of the literature. Pediatr Emerg Care. Feb 1995;11(1):32-4. [Medline].
Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York: McGraw-Hill; 1995.
Rosen P, Barkin R, et al, eds. Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St Louis: Mosby-Year Book; 1996.
Giri AK, Banerjee S. Genetic toxicology of four commonly used benzodiazepines: a review. Mutat Res. Jun 1996;340(2-3):93-108. [Medline].
Greenberg DA, Simon RP. Flexor and extensor postures in sedative drug-induced coma. Neurology. Apr 1982;32(4):448-51. [Medline].
Hamad A, Sharma N. Acute zolpidem overdose leading to coma and respiratory failure. Intensive Care Med. Jul 2001;27(7):1239. [Medline].
Hojer J, Salmonson H, Sundin P. Zaleplon-induced coma and bluish-green urine: possible antidotal effect by flumazenil. J Toxicol Clin Toxicol. 2002;40(5):571-2. [Medline].
Isbister GK, O'Regan L, Sibbritt D, Whyte IM. Alprazolam is relatively more toxic than other benzodiazepines in overdose. Br J Clin Pharmacol. Jul 2004;58(1):88-95. [Medline].
Liskow B, Pikalov A. Zaleplon overdose associated with sleepwalking and complex behavior. J Am Acad Child Adolesc Psychiatry. Aug 2004;43(8):927-8. [Medline].
Lovett B, Watts D, Grossman M. Prolonged coma after eszopiclone overdose. Am J Emerg Med. Jul 2007;25(6):735.e5-6. [Medline].
Meyer S, Kleinschmidt S, Gottschling S, Gortner L, Strittmatter M. [Gamma-hydroxy butyric acid: neurotransmitter, sedative and party drug]. Wien Med Wochenschr. Jul 2005;155(13-14):315-22. [Medline].
Riegel W. Use of continuous renal replacement therapy for detoxification?. Int J Artif Organs. Feb 1996;19(2):111-2. [Medline].
Rossman PG, Knesper DJ. The early phase of hospital treatment for disruptive adolescents! The integration of behavioral and dynamic techniques. J Am Acad Child Psychiatry. 1976;15(4):693-708. [Medline].
Worthley LI. Clinical toxicology: part I. Diagnosis and management of common drug overdosage. Crit Care Resusc. Sep 2002;4(3):192-215. [Medline].
Print
