Opioids/Benzodiazepines Poisoning Clinical Presentation

  • Author: Christopher P Holstege, MD; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Dec 20, 2010
 

History

An event involving an opioid or benzodiazepine aerosolized incapacitating agent would probably create confusion and panic; cause multiple serious injuries or fatalities; and necessitate a major emergency medical service, police, and/or military response.

  • Large numbers of casualties could overwhelm any community's emergency response services.
  • Chaos may occur following such an event.
  • In the early phases of an emergency response, the agent would probably be unknown, and the history may be misleading and inaccurate.
  • Physical examination is the key to identifying the causative agent.
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Physical

Following exposure to either an aerosolized opioid or benzodiazepine incapacitating agent, the presentation would be a syndrome consistent with opioid or benzodiazepine toxicity, respectively. These syndromes can vary, depending on the opioid or benzodiazepine agent used. In addition, findings may vary, depending on the patient's preexisting medical problems, the treatment provided by first responders, and the potential complications of the intoxication. For example, if hypoxic brain injury occurs, the characteristic miosis seen in an opioid syndrome may be replaced by fixed dilated pupils.

  • Opioid intoxication
    • Respiratory depression manifesting as hypoventilation, apnea, and airway occlusion may be present.
    • Central nervous system depression manifesting as fatigue, somnolence, ataxia, and/or coma may be present.
    • Miosis may be present. Intoxication with the opioids meperidine and propoxyphene (withdrawn from US market) does not typically cause miosis, and normal pupillary size is regularly maintained; however, neither of these agents has been associated with aerosolization. Mydriasis may occur in patients with severe toxicity because of anoxic brain injury. Miosis may be limited by preexisting medical conditions, such as a history of previous cataract surgery.
    • Cardiovascular manifestations of opioid toxicity may include hypotension secondary to arteriolar and venous dilation. Both tachycardia secondary to hypotension or hypoxia and bradycardia secondary to a reduction of direct central nervous system stimulation may be observed. If hypoventilation becomes prominent, hypoxia-induced cardiac arrhythmias may occur.
  • Benzodiazepine intoxication
    • Respiratory depression manifesting as hypoventilation, apnea, and airway occlusion may be present.
    • Central nervous system depression manifesting as drowsiness, somnolence, ataxia, nystagmus, and/or coma may be present.
    • Cardiovascular manifestations of benzodiazepines may include hypotension, tachycardia, and bradycardia. Hypoxia-induced cardiac arrhythmias may occur.
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Contributor Information and Disclosures
Author

Christopher P Holstege, MD  Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health

Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, European Association of Poisons Centres and Clinical Toxicologists, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer S Boyle, MD, PharmD  Fellow in Toxicology, University of Virginia Health System

Disclosure: Nothing to disclose.

Specialty Editor Board

Suzanne White, MD  Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References

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