II. Mechanism

III. Signs: Benzodiazepine Intoxication

  1. Classic presentation is Altered Level of Consciousness with normal Vital Signs
  2. Cardiopulmonary effects
    1. Respiratory Depression (esp. when combined with other substances, e.g. Alcohol)
    2. Hypotension
    3. Rarely lethal alone, but dangerous with Alcohol
  3. Neurologic effects
    1. Anterograde Amnesia
    2. Ataxia (esp. young children)
    3. Confusion
    4. Slurred Speech
    5. Miosis
  4. Spectrum of Decreased Level of Consciousness
    1. Drowsiness
    2. Lethargy
    3. Sedation
    4. Coma

IV. Differential Diagnosis

V. Management: Benzodiazepine Overdose

  1. See Unknown Ingestion
  2. Supportive care with airway management for CNS Depression
  3. Benzodiazepines Overdoses in isolation generally have good outcomes
    1. However, coingestion is common, and in combination, Overdose may be lethal
    2. CNS Depression (and apnea) increases when combined with depressants (e.g. Opioids, Alcohol)
  4. Flumazenil (Romazicon)
    1. Read Flumazenil contraindications carefully
    2. Avoid in patients with chronic use (risks of severe withdrawal including Seizures)
      1. Most toxicology guidelines do not recommend Flumazenil in Overdose
      2. Potential harms appear to outweigh benefits in most cases
      3. Penningo (2016) Basic Clin Pharmacol Toxicol 118(1): 37-44 +PMID:26096314 [PubMed]
    3. May be indicated for acute Benzodiazepine Overdose (non-chronic use) with cardiopulmonary depression
      1. Young, healthy children with Accidental Ingestion and no significant prior use

VI. Management: Fake Xanax

  1. Fake Xanax contains Fentanyl and Etizolam (Benzodiazepine analog)
  2. Presents as opiod Overdose with sedation and respiratory depression (Rhabdomyolysis was also associated)
  3. Management
    1. Naloxone 0.4 mg
    2. Supportive care
    3. Consult poison control
  4. References
    1. Swadron and Nordt in Herbert (2017) EM:Rap 17(2):18
    2. ThePoisonReview.com
      1. http://www.thepoisonreview.com/2016/08/24/case-series-8-patients-exposed-to-phony-alprazolam-xanax-containing-fentanyl-andor-etizolam/

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