Approach
Most patients with pure benzodiazepine (BZD) overdose present with mild central nervous system (CNS) depression, particularly sedation with no respiratory depression. Once the diagnosis has been confirmed, they require only observation until metabolism of the BZD leads to a natural recovery.[18]
Supportive care
Clinical treatment of overdose is by symptom management. Acute management consists of maintaining airway, respiration, and hemodynamic support while excluding other diagnoses.
If there is cardiorespiratory depression, pure BZD overdose is unlikely, and treatment should be focused on cardiorespiratory and hemodynamic support, and treating other causes such as alcohol excess or opioid overdose. Assisted ventilation may be necessary.[36]
Flumazenil
Flumazenil reverses CNS depression but does not reliably reverse respiratory depression. The risks of flumazenil often outweigh the benefits. The American Heart Association recommends that it can be effective in select patient groups such as those with respiratory depression or respiratory arrest caused by pure BZD poisoning who do not have contraindications to flumazenil.[34] It may also be safe in some low-risk presentations (e.g., pediatric exploratory ingestions and iatrogenic overdoses during procedural sedation).[34]
Flumazenil can be used in patients who are first-time or infrequent BZD users where the likelihood of BZD overdose is high and there are no known contraindications. Flumazenil can induce seizures in patients who have a history of seizures, are dependent on BZDs, or who take tricyclic antidepressants, and is contraindicated in these groups.[31][32] It should also be avoided where other respiratory depressants have been coingested or if the patient has an undifferentiated coma.
Flumazenil can cause dysrhythmias in patients taking prodysrhythmic medication such as tricyclic antidepressants or carbamazepine. Therefore, it should be given together with ECG monitoring if the history is vague and toxicology results are not yet available. In addition, antiseizure medication should be readily available in the event of a seizure being triggered. Flumazenil has a shorter half-life than most BZDs and so rapid resedation can occur after apparent recovery. Resedation occurs in approximately 30% of patients, increasing their risk of aspiration and death. Close monitoring is required.[38]
Gastric lavage
Most authors suggest that gastric lavage should not be employed routinely, if ever, in the management of poisoned patients because of severe risks including hypoxia, laryngospasm, and aspiration pneumonia.[39] The risks of harm from gastric lavage probably outweigh the benefits in pure BZD overdose. In mixed overdoses, if an extremely toxic substance has been ingested, gastric lavage can be undertaken with extreme care within 1 hour of ingestion.
Activated charcoal
Because BZD overdose is rarely dangerous and most patients do not present within an hour or so of overdose, activated charcoal to reduce absorption is not generally recommended.[40]
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