engleski

Management of acute benzodiazepine intoxication and withdrawal in the Emergency department setting

The last few decades have seen a rise in the prescribing and abuse of benzodiazepines (BZDs). Due to this, there has been an increase in emergency department visits involving drug intoxication with BZDs and withdrawal. Groups at risk are the elderly, pregnant women, children, and individuals with mental health disorders. Although neither of these presentations is typically fatal in BZD use alone, there have been reported fatal cases, along with a large number of fatal cases involving mixed drug intoxication with BZDs. The presentation of isolated BZD intoxication varies from patient to patient, but involves a suppression of the central nervous system, leading to symptoms such as slurred speech, double vision, nystagmus, ataxia, anterograde amnesia, balance/coordination issues, respiratory depression, and sedation. Comatose patients are at high risk for aspiration pneumonia and developing complications such as rhabdomyolysis. Management of BZD intoxication is typically done through supportive care and flumazenil (BZD antagonist) when specific criteria are met. Recent data in the medical community has shown that the use of flumazenil is limited and may cause more harm than benefit, due to increased seizure risk and withdrawal symptom presentation. BZD withdrawal manifests after a cessation or reduction in BZD use after prolonged or high dose exposure. Patients present with autonomic hyperactivity, tactile/visual hallucinations, anxiety, insomnia, nausea/vomiting, hand tremor, and possible grand-mal seizures. Management of BZD withdrawal is typically done through the use of BZDs and implementing a tapering regime involving BZDs to effectively manage symptoms over time. Previous studies have suggested that flumazenil may be of benefit to BZD withdrawal management since patients who have added flumazenil to a tapering regime demonstrated higher success rates in treatment compared to placebo-treated groups. As flumazenil use is typically reserved for patients with severe respiratory depression, sedation, those with isolated BZD intoxication, and individuals who are not taking pro-convulsant drugs, the use of this BZD antagonist is very limited in use. Due to these factors, the management of BZD intoxication and withdrawal proves to be difficult as history and physical examinations may not give enough data to meet criteria for flumazenil use. Goals for reducing the presentation of BZD intoxication and withdrawal should be aimed at primary prevention. Even though benzodiazepine use should be limited at 2-4 weeks, many primary care physicians continue to prescribe BZDs to their patients for chronic use. Ultimately, this leads to an increased population of BZD abusers who are at risk for intoxication and withdrawal.

benzodiazepine ; emergency department ; drug intoxication ; withdrawal ; flumazenil

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