Opioids/Benzodiazepines Poisoning Treatment & Management
- Author: Christopher P Holstege, MD; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD more...
Prehospital care providers must place their personal safety before the treatment of patients who may be contaminated with an incapacitating agent. Emergency responders should not enter a contaminated location that has not been secured. Little is known regarding the risk of secondary contamination in health care providers exposed to patients with contamination from opioid or benzodiazepine aerosolized agents.
For civilian paramedics, exposed patients must be decontaminated prior to transfer. Absorption and subsequent toxicity is a risk from contact with patients who have been contaminated. Paramedics are at increased risk for toxicity in the closed confines of an ambulance. Caution must be exercised, especially for flight crews, because toxicity of the pilot during flight can lead to impaired judgment and subsequent risk of crashing the aircraft.
Initiation of intravenous access and the infusion of intravenous fluids should be considered. Before intubation, naloxone may be administered intravenously to patients with respiratory compromise and suspected opioid toxicity. Aggressive airway control must take precedence over pharmacologic reversal because the vast majority of morbidity and mortality results from respiratory depression.
Emergency Department Care
Once decontamination has occurred, the primary emphasis is simply supportive care of exposed patients. Emergency department staff must be certain that proper decontamination has occurred. Aerosolization of the agents from contaminated patients may occur and can pose a risk to hospital personnel.
Airway protection is paramount. In patients who present with coma, aspiration is a risk if adequate airway protection is not achieved. Hypoglycemia should be considered in all patients presenting with altered mental status and glucose administered when necessary. Naloxone may be infused in an attempt to reverse opioid activity (see Medication). Naloxone has an excellent safety record and is standard therapy in many institutions as part of the so-called coma cocktail. Flumazenil may be considered with caution because a number of contraindications exist in its use (see Medication). Thiamine administration should be considered in patients presenting with altered mental status.
Care may also include the following:
Intravenous hydration may be necessary; maintain adequate urinary output. Consider placement of a Foley catheter to monitor the patient's urine output.
Include continuous cardiac monitoring in patients who are symptomatic.
If an exposure to aerosolized benzodiazepines or opioids occurs, consider a number of consultations.
Medical toxicologists: Consider consulting these physicians early to assist in the diagnosis and appropriate treatment of patients with possible exposure to these aerosolized agents.
Critical care specialists: For patients requiring intensive care monitoring, consider early consultation with a physician trained in critical care medicine.
Law enforcement: If the cause of the exposure is a terrorist act against civilians, immediately contact the local law enforcement agency, health department, and poison control center. Also, contact federal agencies, such as the US Federal Bureau of Investigations (FBI).
Stone A. Chemical weapons. U.S. research on sedatives in combat sets off alarms. Science. 2002 Aug 2. 297(5582):764. [Medline].
Riches JR, Read RW, Black RM, Cooper NJ, Timperley CM. Analysis of clothing and urine from Moscow theatre siege casualties reveals carfentanil and remifentanil use. J Anal Toxicol. 2012 Nov-Dec. 36:647-656. [Medline].
Chan S. Lethal Moscow Gas An Opiate?. CBS. October 29, 2002. Available at http://www.cbsnews.com/news/lethal-moscow-gas-an-opiate/.
Fallahinejad Ghajari M, Ansari G, Soleymani AA, Shayeghi S, Fotuhi Ardakani F. Comparison of Oral and Intranasal Midazolam/Ketamine Sedation in 3-6-year-old Uncooperative Dental Patients. J Dent Res Dent Clin Dent Prospects. 2015 Spring. 9 (2):61-5. [Medline].
Siegel RA, Kapoor M, Cheryala N, Georg GI, Cloyd JC. Water-soluble benzodiazepine prodrug/enzyme combinations for intranasal rescue therapies. Epilepsy Behav. 2015 Aug. 49:347-50. [Medline].
Hess L, Schreiberova J, Fusek J. Pharmacological non-lethal weapons. 3rd European Symposium on Non-Lethal Weapons. May 10-12, 2005. Available at http://www.non-lethal-weapons.com/sy03abstracts/V23.pdf. Accessed: August 18, 2015.
Xi LY, Zheng WM, Zhen SM, Xian NS. Rapid arrest of seizures with an inhalation aerosol containing diazepam. Epilepsia. 1994 Mar-Apr. 35(2):356-8. [Medline].
Booij LH. [The agent used to free the hostages in Moscow and the insufficient Dutch preparations in case of a terrorist chemical disaster]. Ned Tijdschr Geneeskd. 2002 Dec 14. 146(50):2396-401. [Medline].
Brooks M. Knockout gas: Chemical weapons in disguise?. New Scientist. October 2007. [Full Text].
Coupland RM. Incapacitating chemical weapons: a year after the Moscow theatre siege. Lancet. 2003 Oct 25. 362(9393):1346. [Medline].
Dando M. Biologists napping while work militarized. Nature. 2009 Aug 20. 460(7258):950-1. [Medline].
Enserink M, Stone R. Toxicology. Questions swirl over knockout gas used in hostage crisis. Science. 2002 Nov 8. 298(5596):1150-1. [Medline].
Gudmundsdottir H, Sigurjonsdottir JF, Masson M, et al. Intranasal administration of midazolam in a cyclodextrin based formulation: bioavailability and clinical evaluation in humans. Pharmazie. 2001 Dec. 56(12):963-6. [Medline].
Hung OR, Whynot SC, Varvel JR, et al. Pharmacokinetics of inhaled liposome-encapsulated fentanyl. Anesthesiology. 1995 Aug. 83(2):277-84. [Medline].
Ljungman G, Kreuger A, Andreasson S, et al. Midazolam nasal spray reduces procedural anxiety in children. Pediatrics. 2000 Jan. 105(1 Pt 1):73-8. [Medline].
Loftsson T, Gudmundsdottir H, Sigurjonsdottir JF, et al. Cyclodextrin solubilization of benzodiazepines: formulation of midazolam nasal spray. Int J Pharm. 2001 Jan 5. 212(1):29-40. [Medline].
Mather LE, Woodhouse A, Ward ME. Pulmonary administration of aerosolised fentanyl: pharmacokinetic analysis of systemic delivery. Br J Clin Pharmacol. 1998 Jul. 46(1):37-43. [Medline].
Rieder J, Keller C, Hoffmann G. Moscow theatre siege and anaesthetic drugs. Lancet. 2003 Mar 29. 361(9363):1131. [Medline].
Schiermeier Q. Hostage deaths put gas weapons in spotlight. Nature. 2002 Nov 7. 420(6911):7. [Medline].
Wax PM, Becker CE, Curry SC. Unexpected "gas" casualties in Moscow: a medical toxicology perspective. Ann Emerg Med. 2003 May. 41(5):700-5. [Medline].
Worsley MH, MacLeod AD, Brodie MJ, et al. Inhaled fentanyl as a method of analgesia. Anaesthesia. 1990 Jun. 45(6):449-51. [Medline].