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Home | Articles | Poisoning | Benzodiazepines

Benzodiazepines

Last updated 3rd December 2020

Last updated on 14th May 2014 by Calum Murray

Toxicity

  1. Serious toxicity is rare
  2. Adults who have accidentally ingested less than 0.5 mg/kg and have no symptoms do not usually need referral to A&E.
  3. The frail elderly and those with severe liver disease are at risk of toxicity from lower doses.
  4. Refer if any of the following apply:
    1. recent ingestion of 0.5 mg/kg or more.
    2. patient is symptomatic.
    3. patient has taken a deliberate overdose.
  5. Patients who are asymptomatic at 4 hours are unlikely to develop severe toxicity.

Clinical Features

  1. Benzodiazepines commonly cause drowsiness, ataxia, dysarthria and nystagmus. 
  2. Coma, hypotension, bradycardia and respiratory depression occasionally occur but are seldom serious if these drugs are taken alone. Coma usually lasts only a few hours but may be prolonged in elderly patients. 
  3. Benzodiazepine respiratory depressant effects are more serious in patients with severe chronic obstructive airways disease. Severe effects in overdose also include rhabdomyolysis and hypothermia.
  4. Co-ingestion of alcohol and other central nervous system depressants potentiates the effects of benzodiazepines and can increase toxicity.

General Management

  1. Always use the ABCDE approach
  2. The benefit of gastric decontamination is uncertain. Consider activated charcoal 50 g in adults who have taken a potentially toxic amount within 1 hour, provided the airway can be protected.
  3. Monitor level of consciousness, respiratory rate, pulse oximetry and blood pressure in symptomatic patients.
  4. Consider arterial blood gas analysis in patients who have a reduced level of consciousness (GCS < 8; AVPU scale P or U) or have reduced oxygen saturations on pulse oximetry.

Flumazenil

  1. Flumazenil is a specific benzodiazepine antagonist,. Avoid if history of convulsions and in those who have co-ingested TCAs, as can precipitate seizures and ventricular arrhythmias. 
  2. Give IV over 30 seconds, repeating as necessary to obtain the desired clinical response i.e. adequate airway protection and ventilation). It is not necessary or appropriate in cases of poisoning to fully reverse the benzodiazepine effect.
  3. First dose: 0.2 mg (200 micrograms/2 mL). Wait 30 seconds. If unsuccessful – Second dose: 0.3 mg (300 micrograms/3 mL). Wait 30 seconds. If unsuccessful – Third and subsequent doses: 0.5 mg (500 micrograms/5 mL) 
  4. If no response after a total dose of 2 mg within a few minutes it is unlikely that flumazenil will reverse the CNS/respiratory depression.
  5. Not more than 3 mg should be given within one hour.
  6. If drowsiness recurs, doses can be repeated at 20 minute intervals or as an intravenous infusion of 0.1-0.5 mg/hour (100-500 micrograms/hour), adjusted to individual response.

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