Recommendations
Key Recommendations
Most patients with pure benzodiazepine (BZD) overdose present with mild central nervous system (CNS) depression, particularly sedation with no respiratory depression. Once the diagnosis has been confirmed, they require only observation until metabolism of the BZD leads to a natural recovery.[18]
If deliberate overdose has taken place, request a specialist mental health assessment at the earliest opportunity.[32] See Suicide risk mitigation.
Supportive care
Clinical treatment of overdose is by symptom management. Acute management consists of maintaining airway, respiration, and hemodynamic support while excluding other diagnoses. Patients require cardiac monitoring and pulse oximetry with consideration of end tidal CO2.
If there is cardiorespiratory depression, pure BZD overdose is unlikely, and treatment should be focused on cardiorespiratory and hemodynamic support, and treating other causes such as alcohol excess or opioid overdose. The American Heart Association (AHA) states that naloxone should be administered when mixed opioid and BZD overdose is suspected.[1] Assisted ventilation may be necessary.[33] If the patient is hypotensive, ensure adequate fluid resuscitation, and additional measures such as vasopressors if required.
Consult the Poison Center to discuss the patient's presentation, toxicity, and management considerations. Poison Help Opens in new window
Flumazenil
Flumazenil reverses CNS depression; however, the risks of flumazenil often outweigh the benefits and its use is inappropriate for most patients presenting to the emergency department with BZD toxicity. Flumazenil should only be considered in patients who are known to have pure BZD poisoning (such as during procedural sedation) and should be avoided where other respiratory depressants are known to have been coingested or if the patient has an undifferentiated coma and medical history, substance use history, and the potential poisons involved are unknown.[1] Flumazenil can induce seizures in patients who have a history of seizures, who are dependent on BZDs, or who have also ingested a proconvulsant, such as a tricyclic antidepressant, and is contraindicated in these groups.[34][35]
The AHA states that flumazenil can be effective in select patient groups such as those with respiratory depression or respiratory arrest caused by pure BZD poisoning who do not have contraindications to flumazenil.[1] Flumazenil may prevent the need for intubation and mechanical ventilation; however, it is associated with harm in patients who are at increased risk for seizures or dysrhythmias.
Flumazenil has a shorter half-life than most BZDs and so rapid resedation can occur after apparent recovery. Resedation occurs in approximately 30% of patients, increasing their risk of aspiration and death. Close monitoring is required.[36]
Activated charcoal
Use of activated charcoal is not routinely recommended in the management of poisoned patients, but may be considered if the patient presents to hospital within an hour of ingestion of a toxic dose.[37] The patient must be conscious and able to protect their airway for safe administration of activated charcoal; therefore, the clinical effects of BZD toxicity often contradict its use.
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