Benzo Overdose

[tcripp]

We had a patient the other day with a highly suspected benzo overdose. Our truck does not carry flumazenil - so we essentially maintain, treat what we can and transport appropriately.

With that being said, there came a point to where our pt was unconscious/unresponsive and we decided to fly the patient to the nearby big city (remember, I'm rural). When the air crew boarded the box, they pushed the Romazicon and, voila, we are alert and oriented once again.

After some additional reading on the anti-dote, there are lots of nasty little issues with the drug. Wondering what protocol your service has and, if you've used this drug before, what you've seen both good and bad.

I'm hoping that someone else's field experience will help me to better understand the drug.

Toni

[ERDoc]

Flumazenil does have some nasty side effects that have been discussed in other threads, the biggest being seizures. I've used it once without any problems and with good results. I only use it to prevent intubating someone. The one time I used it, the pt was cyanotic, hypoxic and a bit difficult to bag.

[Kiwiology]

Flumazanil is right up there with Satanisim .... far better to provide good oxygenation/circulatory support and take to hospital

I done about reckon we should be doing the same for most ODs and shouldn't really be waking them up with naloxone

[krumel]

I actually used Flumazenil a few times (four or five times I think), in one case in a "CV/CI" situation after we a Ketamine+midazolam+suxamethonium RSI.

We have no real protocols regarding Flumazenil but we try to titrate it to a dose that does not make the patient "wake up" but reduces your A/B problem. Same thing here with naloxone..We try to use only minimal dose of both drugs to prevent the side effects... During my internship at a toxikology-ICU I once saw an patient going totally psychotic after Flumazenil+Naloxone administration given after a massive overdose. The patient broke his own arm trying to get out of the restrains...They tried to "chemical restrain" him with other drugs but this happend before the drug started working....

[chbare]

The problem with benzo reversal is similar to reversal of narcotic overdoses with dependency and addiction issues. However, with benzo reversal you have additional risks. A patient can develop withdraw, hallucinations, aggressive behaviour and seizures. Unfortunately, the very medications that can treat these problems are not going to be effective. This is a bad place to be in. Unfortunately, it's not even treatable with say a paralytic because paralytics primarily effect peripheral nicotinic acetylcholine receptors. The only practical use I have for reversal agents is in benzo naive patients receiving procedural sedation.

[Krysteen]

Interesting topic:) Actually had the exact same patient presentation. Bottle of benzos empty. Note written. Pt unresponsive. Gave romazicon per protocol and was later pulled aside by ER doc and was informed that treating benzo overdose with romazicon has changed primarily because had my patient had rebound seizures, which has become increasingly common, I would have had no way of treating them. This was one of three times our service was warned, each a diff medic, in the last six months. So we we have since changeed our protocol for use only as a adjunct to our administration of benzos if reversal is warranted.

[rock_shoes]

The tendency I've seen in managing Benzo overdoses everywhere I've worked is to manage the airway and monitor/maintain hemodynamics/perfusion until the Benzo wears off. I tend to agree with that management strategy over using flumazenil for the afforementioned reasons. Better to stick a tube than precipitate siezures and render your first line drugs useless all at the same time.

[zippyRN]

The problem with benzo reversal is similar to reversal of narcotic overdoses with dependency and addiction issues. However, with benzo reversal you have additional risks. A patient can develop withdraw, hallucinations, aggressive behaviour and seizures. Unfortunately, the very medications that can treat these problems are not going to be effective. This is a bad place to be in. Unfortunately, it's not even treatable with say a paralytic because paralytics primarily effect peripheral nicotinic acetylcholine receptors. The only practical use I have for reversal agents is in benzo naive patients receiving procedural sedation.

yes and the UK product licence says as much as does ToxBASE

[Doczilla]

I am not a fan of flumazenil for the reasons stated above. You can unmask seizures caused by other coingestants, or cause withdrawal seizures in the patient who is benzo-tolerant or addicted to alcohol. Your only therapeutic choices once they occur is putting them in a coma with propofol or pentobarb. I do not think flumazenil has a place in the prehospital or ED treatment of benzo overdose. The only scenario in which I would give it is a patient that is not taking benzos or a drinker, after being oversedated with versed during a procedure.

Benzo overdose is not terribly harmful so long as you can protect the airway and ensure oxygenation. For the benzo overdose that is hypoxic, hypoventilating, or lacks a gag reflex, I just intubate them and let the drugs wear off. It is safer in my mind than the "instant gratification" of reversing the OD with flumazenil and causing status epilepticus, which could be life threatening. Even if unresponsive, if they have a decent pulse ox and a gag, I'm not going to intubate them.

I was not on the call, and the only info I have is what you have described here, but I can't say that I agree with the use of air medical transport in this case unless the flight crew had the ability to manage the airway that you didn't. A helicopter transport is very expensive, not as safe as ground transport (due not only to aircraft mishaps, but the inability to assess the patient in flight due to noise and vibration). The question to ask is, what benefit will be conveyed to the patient by transporting to the "big city" hospital rather than the community hospital? In trauma, the decreased transport time is helpful but ONLY if the patient goes directly to the operating room, which is a tiny subset of trauma patients. In MI, there is a measurable decrease in survival for every 30 minutes that catheterization is delayed. In stroke, the time delay may mean the difference between thrombolytic therapy (or percutaneous neurointervention) or not. But the vast majority of other patients, even critically ill ones, will not see much of a benefit in arriving at the hospital that much sooner. In ALS systems, we have the ability to treat shock, fluid resuscitate, manage the airway, start pressors, treat arrhythmias, and relieve pain. Is there any reason, then, for the risk we put ourselves, the patient, and the commuting public at risk by rushing as fast as we possibly can to the hospital? We are encouraging dangerous behavior on the part of our EMS providers by doing so, and conveying great expense at the same time.

'zilla

[tcripp]

I was not on the call, and the only info I have is what you have described here, but I can't say that I agree with the use of air medical transport in this case unless the flight crew had the ability to manage the airway that you didn't. A helicopter transport is very expensive, not as safe as ground transport (due not only to aircraft mishaps, but the inability to assess the patient in flight due to noise and vibration). The question to ask is, what benefit will be conveyed to the patient by transporting to the "big city" hospital rather than the community hospital?

Big city vs local hospital...ICU capabilities.

Fly vs drive...total time in managing an intubated airway possibly without a vent (manual ventilations).

I do like your thought process on the fly vs. drive thing. Not to segue my own thread, but one area I (as a new medic) am struggling with is when is it best to fly vs drive especially when you factor in quality of life in to the equation AND code 1 vs code 3. I've personally seen a time saving difference of minutes between the two and truly feel that if we are driving, we probably could manage the patient for an additional few minutes in the grand scheme.