Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department?
ABSTRACT Patients in coma with suspected drug poisoning are commonly encountered in the emergency department. Benzodiazepines are one of the most commonly used drugs in self-poisoning. Flumazenil, a benzodiazepine antagonist has been suggested as a diagnostic and treatment tool in suspected poisoning of unclear cause, but caution is required due to potential side effects. No systemic review of this literature has been done on this topic.
The aim of this study is to examine if flumazenil should be used in patients with coma from suspected drug poisoning.
Randomised controlled trials were identified from the Cochrane Library, Pubmed and EMBASE. Bibliographies from included studies, known reviews and texts were searched. Content experts were contacted.
Randomised controlled trials were eligible for inclusion. Studies were included if patients who presented with altered mental state from suspected drug poisoning were treated with intravenous flumazenil as compared to placebo.
Data were extracted and methodological quality was assessed independently by two reviewers.
Seven randomised controlled trials were included. A total of 466 patients were involved. Flumazenil was found to reverse coma from suspected drug poisoning with a relative benefit of 4.45 (95% CI 2.65, 7.45). In terms of major side effects, there was no statistical difference between flumazenil and placebo (RR 2.86, 95% CI 0.12-69.32). However, in terms of minor side effects, flumazenil was associated with a higher incidence of anxiety (RR 2.84, 95% CI 1.28-6.30) and other side effects (RR 3.73, 95% CI 2.078-6.73). There was no difference in the incidence of vomiting (RR 4.28, 95% CI 0.95-19.35).
Current evidence shows that flumazenil may be effective in the reversal of coma in patients presenting to the emergency department with coma from suspected drug poisoning.
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ABSTRACT: Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. It is imperative for the critical care team to have a high index of suspicion for substance intoxication and withdrawal. This article reviews the epidemiology of substance use in this population and the treatment of common withdrawal syndromes. General principles regarding the management of substance withdrawal syndromes include general resuscitative measures, use of a symptom-triggered approach, and substitution of a long-acting replacement for the abused drug in gradual tapering dose. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.Critical Care Clinics 11/2008; 24(4):767-88, viii. DOI:10.1016/j.ccc.2008.05.005 · 2.50 Impact Factor
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ABSTRACT: We bespreken twee adolescenten met een bewustzijnsdaling door onbekende oorzaak. Deze casus illustreren hoe intoxicaties zich bij adolescenten kunnen presenteren en welke klinische overwegingen zich hierbij voordoen. Patiënt 1, een 13-jarige jongen, werd door zijn vader binnengebracht.Wegens bewustzijnsdaling e.c.i. werd flumazenil toegediend, waarna hij weer bij bewustzijn kwam. Patiënt 2, een 16-jarig meisje, werd bewusteloos binnengebracht door ambulancepersoneel. Een (hetero)anamnese was niet mogelijk. Op klinische gronden werd een intoxicatie met gammahydroxyboterzuur (GHB) vermoed. Dilemma’s met betrekking tot de therapeutische benadering (intubatie en medicatie) worden besproken. Als leerpunten komen uit dit tweetal patiëntencasus naar voren: de diagnostische waarde van flumazenil bij bewustzijnsverlies e.c.i. en de benadering van mogelijke GHB-intoxicaties bij adolescenten in de acute situatie.Tijdschrift voor kindergeneeskunde 10/2012; 80(5). DOI:10.1007/s12456-012-0034-2
Article: Toxicology in the critical care unit[Show abstract] [Hide abstract]
ABSTRACT: Toxicologic conditions are encountered in critically ill patients due to intentional or unintentional misuse of or exposure to therapeutic or illicit drugs. Additionally, toxicities related to medical interventions may develop in hospitalized patients. This review focuses on recent developments in the field of critical care toxicology. Early interventions to decrease absorption or enhance elimination of toxins have limited value. Specific interventions to manage toxicities due to analgesics, sedative-hypnotics, antidepressants, antipsychotics, cardiovascular agents, alcohols, carbon monoxide, and cholinergic agents are reviewed. Hospital-acquired toxicities due to methemoglobinemia, propylene glycol, and propofol should be recognized and treated. The clinician is continually required to incorporate clinical judgment along with available scientific data and clinical evidence to determine the best therapy for toxicologic conditions.Chest 05/2008; 133(4):1006-13. DOI:10.1378/chest.07-1840 · 7.13 Impact Factor