HWN Suggests

What’s the Deal with Flumazenil?

So why is flumazenil seen as such an evil drug to use in the emergency department?

This agent, like naloxone, has one indication – make people breath again. It is NOT for awakening the unconscious; there are no data that it is a good diagnostic aid that could obviate the need for a workup.

I think flumazenil has overall received too much of a bad rap…and I will certainly use it on patients who have CNS depression with questionable ventilation. I do NOT use it as a diagnostic agent. Of note, I have used in pts who I know are benzo dependent. As with all we do, this is a risk/benefit analysis.

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  Sedative Toxidrome

0pioids. benzodiazepines. barbiturates. baclofen (may mimic brain death, suspect in MS patients). clonidine (mimics opioid toxidrome with marked bradycardia and hypotension). GHB.

 CRACKCast E165 – Sedative Hypnotics

What Benzos WILL NOT be detected on urine drug screen? Clonazepam, Lorazepam, Midazolam, Alprazolam, Flunitrazepam.

Articles of Interest

Don’t Eat That: Tips to Care for Patients with Toxic Exposures

Sedative-Hypnotic Toxidrome. This includes anticonvulsants, benzodiazepines, alcohol, barbiturates and z-drugs. Clinical picture is similar to opioid toxidrome, but respiratory depression isn’t as extreme, and eyes may have no pupillary change. Patients will likely have signs of delirium and/or hallucinations.

Management of Sedative–Hypnotic Intoxication and Withdrawal

A clinically significant withdrawal syndrome is likely to occur after discontinuation of a high-dose sedative–hypnotic previously taken for 2 to 3 months or a low-dose sedative–hypnotic previously taken for 4 to 6 months. It should be noted, however, that withdrawal symptoms can occur sooner and are influenced by three main factors: dose, duration of use, and duration of drug action.

Opioids & Sedatives Toxicity

Flumazenil: Nonspecific competitive antagonist of the benzo receptor. Reverse benzodiazepine-induced sedation after GA, PSA, & confirmed benzodiazepine overdose. Not recommended for the routine reversal of sedative overdose in the ED.

Toxicology 101: Talking Tox with The Dantastic Mr. Tox & Howard

Patients are sleepy because of increased inhibitory control of the brain. Most overdoses are due to polypharmacy and sedatives are usually the least toxic component. In fact, they may help keep the patient comfortable and just sleep it off.

Toxidromes: Common Poisoning Syndromes to Know

Since the sedative-hypnotic overdoses are easily mistaken for an opioid overdose, it is important to inquire as to prescribed medications and search the scene for pill bottles that may provide clues as to the patient’s toxidrome origin.

Resources

Flumazenil

Flumazenil is a specific ‘antidote’ for benzodiazepine toxicity, but its use is much more controversial that naloxone. This is because its use in benzo dependent patients or in the presence of co-ingestants can precipitate withdrawal and a high risk of seizures. If it is indicated, it is given via careful titration - 0.2mg/min.

GBL Overdose and what to do about it

GBL (Gamma Butylrolactone) otherwise known as G, Gina or liquid ecstasy is a clear colourless liquid with a distinctly chemically metallic taste as oppose to it’s little brother GHB (Gamma hydroxybutyrate) which is described as tasting salty. Classically GHB/GBL overdose is characterised by a rapid onset of CNS and respiratory depression.

StatPearls

Anxiolytics are a class of medications aimed at treating patients with panic disorders, generalized anxiety, and various other uses. Sedatives(hypnotics) are a class of drugs used in different situations ranging from treating insomnia to treating someone connected to a mechanical ventilator.

WikEM

Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan. Withdrawal from substances have the opposite effect