Sedative-Hypnotic Toxicity Treatment & Management

• Establish ABCs, obtain IV access, provide oxygen, and perform aggressive supportive care with airway protection as necessary.
• Ipecac syrup is not recommended for home use because of the fear of emesis after onset of respiratory depression.
• Ensure adequate airway and ventilation. Consider and reassess the need for endotracheal intubation.

General

• Given that the major issues in an overdose are aspiration, respiratory depression or failure, hypoxia, hypotension, and cardiac arrhythmias, the most important aspects in managing an overdose situation are, as usual, the ABCs — airway, breathing, and circulation.

Prevention of absorption

• Gastric lavage may be performed if the patient presents obtunded within 1 hour of ingestion or rapidly deteriorates while in the emergency department. The airway should be secured in such instances prior to gastric intubation and lavage.
• The use of activated charcoal has become debated, and its liberal use is discouraged. In general, measures to prevent absorption (eg, emesis, gastric lavage) or increase excretion (eg, diuresis, catharsis) of the drug have not been shown consistently to reduce mortality associated with drug toxicity. Considerable morbidity is associated with charcoal aspiration. Its use should be limited to substances that would be well absorbed and have a high likelihood of toxic dose ingestion.
• It is not recommended in instances in which GHB or GBL are known to be the only intoxicants.
• Multi-dose activated charcoal (20-50 g q4h) is recommended for overdoses with barbiturates, glutethimide, and meprobamate.

Elimination enhancement

• Alkaline diuresis enhances elimination of phenobarbital and other long-acting barbiturates. It is recommended for all symptomatic patients with long-acting barbiturate toxicity.
• Consider hemodialysis or hemoperfusion in glutethimide, methyprylon, phenobarbital, meprobamate, and chloral hydrate poisoning.

Flumazenil

• Flumazenil competitively and reversibly binds benzodiazepine receptors (ie, GABA).
• The use of flumazenil for suspected benzodiazepine overdoses is controversial. Some sources would go so far as to suggest that flumazenil has no role in the routine treatment of a coma unless the patient is known not to be benzodiazepine dependent and the overdose is known to result only from benzodiazepines. If used, flumazenil should be administered slowly (0.2 mg/min up to 3-5 mg) because large doses cause agitation and withdrawal. Serious risk of inducing seizures exists, particularly in patients with co-ingestions or long-term use of benzodiazepines.
• This drug is contraindicated in patients with increased intracranial pressure (ICP) or closed head injury (CHI), those with a history of epilepsy, or those known to have ingested a tricyclic antidepressant (TCA) agent.

Meprobamate

• Forced diuresis
• Hemodialysis in severe intoxication
• Whole bowel irrigation (recommended for serious meprobamate poisoning because of the high predilection for bezoar formation)

Methaqualone (Quaalude)

• No diuresis
• Diazepam for severe tonicity or seizures (strongly consider phenytoin as an anticonvulsant because barbiturates potentiate this drug)

Chloral hydrate

• Lidocaine may be used for ventricular dysrhythmias.
• Beta-blockers (eg, propranolol) and overdrive pacing have also been reported to be effective. Intravenous propranolol is, perhaps, the drug of choice for chloral hydrate-associated ventricular dysrhythmias. Chloral hydrate sensitizes the myocardium to catecholamines, and propranolol blocks this effect.
• Strongly avoid beta-adrenergic agonists (eg, dopamine) because they increase risk of fatal dysrhythmias.
• Consider hemodialysis.

Consider a consultation with a toxicologist and psychiatrist.