Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – supportive care

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1st line – 

supportive care

Management of pure benzodiazepine (BZD) overdose is supportive, consisting of airway maintenance, cardiorespiratory monitoring and support, and intravenous fluids. Mixed overdose and other causes of central nervous system depression should be ruled out.

Most authors suggest that gastric lavage should not be employed routinely, if ever, in the management of poisoned patients because of the 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.

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]

Consider – flumazenil

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flumazenil

Treatment recommended for SOME patients in selected patient group

Flumazenil, a BZD antagonist, temporarily reverses central nervous system (CNS) depression, but does not reliably reverse respiratory depression. The American Heart Association recommends that flumazenil can be effective in select patients 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]​ Previously it has been used to reverse CNS depression in 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 co-ingested 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, anticonvulsants 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]

Primary options

flumazenil: 0.2 mg intravenously given over 30 seconds; may give a further 0.3 mg after 30 seconds if necessary; further doses of 0.5 mg may be given at 1 minute intervals as necessary, maximum 3 mg total dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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