• 67-year-old, known case of psychiatric illness, on medication:
  • Quetiapine (Quitipin) 200 mg - dosing unclear
  • Trihexyphenidyl 2 mg - likely 1-1-0
  • Olanzapine - dose unclear
  • Lorazepam 2 mg - likely 0-0-1
• “Patient was found unconscious on the floor.”
• On examination: drowsy, arousable to pain, localizing to pain.
• Other written orders appear to include MRI brain, ECG, and ABG.

Suspected sedative overdose: current emergency management

First actions: ABCDE and monitoring

1. Airway
   • Put the patient in the recovery position if breathing spontaneously.
   • Suction secretions and protect the airway.
   • Early endotracheal intubation is indicated for loss of airway reflexes, persistent reduced consciousness, aspiration, hypoventilation, or worsening oxygenation.
2. Breathing
   • Give supplemental oxygen, assess respiratory rate and oxygen saturation.
   • Obtain blood gas, preferably including CO2 assessment, if there is significant CNS depression or suspected hypoventilation.
   • Continuous pulse oximetry and, where available, capnography. Escalate to assisted ventilation/mechanical ventilation when needed.
3. Circulation
   • Cardiac monitor, IV access, frequent blood pressure and temperature checks.
   • ECG, bedside glucose, and targeted labs including electrolytes, renal/liver function, blood gas, and acetaminophen level when deliberate or uncertain ingestion is possible.
   • Treat hypotension initially with IV crystalloid; manage dysrhythmias based on the suspected co-ingestant and toxicology advice.

Identify what was taken

• Exact drugs, strengths, approximate amount and time taken
• All possible co-ingestants: opioids, alcohol, paracetamol/acetaminophen, antidepressants, antipsychotics, stimulants
• Prescribed long-term benzodiazepine use or epilepsy history
• Medication packets, photos, and pharmacy records
• Intentional versus accidental ingestion

Decontamination

• Do not induce vomiting.
• Activated charcoal is not routinely used for a sedated patient because aspiration can be dangerous.
• It may be considered only by a toxicology service for selected early, potentially dangerous ingestions after the airway is protected. The sedative-hypnotic toxicity guidance specifically cautions against charcoal in isolated benzodiazepine poisoning because of aspiration risk.

Antidotes

• Give naloxone promptly if opioid exposure is possible or cannot be excluded and there is respiratory depression.
• A response does not rule out co-ingested sedatives, and recurrent sedation can occur because naloxone may wear off before the opioid.

• Not routine in an unknown, intentional, or mixed overdose.
• It can reverse benzodiazepine sedation but can precipitate seizures, withdrawal, dysrhythmias, and re-sedation. The AHA notes that its risks and contraindications substantially limit its use.
• Avoid or use only with senior toxicology advice if there is:
  • Long-term benzodiazepine use or possible dependence
  • Seizure disorder
  • Unknown/mixed overdose
  • Suspected tricyclic-antidepressant or other pro-convulsant co-ingestion
  • Head injury or raised intracranial pressure

Observation and disposition

• Admit or observe patients with altered consciousness, respiratory depression, suspected long-acting agents, co-ingestants, deliberate self-poisoning, aspiration risk, abnormal ECG/labs, or unreliable history.
• ICU/HDU is appropriate for patients requiring airway protection, ventilation, vasoactive support, seizures, or significant dysrhythmias.
• Before discharge after intentional ingestion: psychiatric assessment, safety planning, and review of access to medications are required.

Relevance to the note you shared

Latest guidance: flumazenil in suspected benzodiazepine poisoning

Do not give flumazenil routinely for undifferentiated coma or suspected sedative overdose. Prioritize airway protection, ventilation, monitoring, and treatment of possible opioid toxicity with naloxone.

When it may be appropriate

• Reversal of iatrogenic oversedation after a benzodiazepine given for a procedure.
• Accidental, isolated benzodiazepine ingestion in a benzodiazepine-naive patient, often a child with a reliable history.
• Selected patients with confirmed benzodiazepine-induced respiratory/CNS depression when contraindications have been actively excluded.

When flumazenil should generally be avoided

• Unknown or mixed ingestion
• Long-term benzodiazepine use, dependence, or likely withdrawal risk
• Seizure disorder, or benzodiazepines being used for seizure control
• Suspected ingestion of a tricyclic antidepressant or another seizure-promoting drug
• ECG features or clinical signs compatible with sodium-channel blocker toxicity, such as wide QRS, significant dysrhythmia, anticholinergic findings, or hypotension
• Head injury, suspected raised intracranial pressure, or unexplained coma
• Inability to provide continuous monitoring and immediate seizure/airway management

Practical toxicology approach

1. Stabilize airway, breathing, and circulation first. Give oxygen, use continuous ECG and respiratory monitoring, obtain glucose and ECG, and intubate/ventilate when airway reflexes or ventilation are inadequate.
2. Consider naloxone first when opioid co-exposure is possible, especially with hypoventilation. Flumazenil does not reverse opioid toxicity.
3. If flumazenil is selected, use small, titrated IV doses under monitored care, not a large empiric bolus.
4. Observe for at least 2 hours for recurrent sedation, respiratory depression, withdrawal, or seizures. Flumazenil has a shorter duration of action than many benzodiazepines. Monitoring guidance
5. Consult a regional poison center or medical toxicologist for deliberate, mixed, severe, or uncertain overdoses.

Newer evidence

Applied to the note previously shown