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Zamani N, Hassanian-Moghaddam H, Zamani N. Strategies for the treatment of acute benzodiazepine toxicity in a clinical setting: the role of antidotes. Expert Opin Drug Metab Toxicol 2022; 18:367-379. [PMID: 35875992 DOI: 10.1080/17425255.2022.2105692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although not a potentially life-threatening poisoning, benzodiazepine (BZD) intoxication may be life-threatening in special situations/populations or those with background diseases. AREAS COVERED The aim of this review is to evaluate all possible treatment options available in the literature for the management of benzodiazepine poisoning with special attention to antidote administration. We conducted a literature search using PubMed, Google Scholar, EMBASE, and Cochrane central register from 1 January 1980 to 10 November 2021 using keywords 'benzodiazepine,' 'poisoning,' 'toxicity,' 'intoxication,' and 'treatment.' EXPERT OPINION Careful patient selection, ideally by a clinical toxicologist, may decrease the complications of flumazenil and add to its efficacy. The cost-to-benefit ratio should be considered in every single patient who is a candidate for flumazenil administration. In case a decision has been made to administer flumazenil, careful consideration of the possible contraindications is essential. We recommend slow administration of low doses of flumazenil (0.1 mg/minute) to avoid complications or withhold the administration with development of first signs of adverse effects. The main treatment of benzodiazepine toxicity is conservative with administration of activated charcoal, monitoring of the vital signs, prevention of aspiration and development of deep vein thrombosis due to prolonged immobilization, and respiratory support.
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Affiliation(s)
- Nasim Zamani
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naghmeh Zamani
- Department of Biology, Tehran North Branch, Islamic Azad University, Tehran, Iran
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Francoeur CL, Lauzier F, Brassard P, Turgeon AF. Near Infrared Spectroscopy for Poor Grade Aneurysmal Subarachnoid Hemorrhage-A Concise Review. Front Neurol 2022; 13:874393. [PMID: 35518206 PMCID: PMC9062216 DOI: 10.3389/fneur.2022.874393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Delayed cerebral ischemia (DCI) disproportionately affects poor grade aneurysmal subarachnoid hemorrhage (aSAH) patients. An unreliable neurological exam and the lack of appropriate monitoring leads to unrecognized DCI, which in turn is associated with severe long-term deficits and higher mortality. Near Infrared Spectroscopy (NIRS) offers simple, continuous, real time, non-invasive cerebral monitoring. It provides regional cerebral oxygen saturation (c-rSO2), which reflects the balance between cerebral oxygen consumption and supply. Reports have demonstrated a good correlation with other cerebral oxygen and blood flow monitoring, and credible cerebrovascular reactivity indices were also derived from NIRS signals. Multiple critical c-rSO2 values have been reported in aSAH patients, based on various thresholds, duration, variation from baseline or cerebrovascular reactivity indices. Some were associated with vasospasm, some with DCI and others with clinical outcomes. However, the poor grade aSAH population has not been specifically studied and no randomized clinical trial has been published. The available literature does not support a specific NIRS-based intervention threshold to guide diagnostic or treatment in aSAH patients. We review herein the fundamental basic concepts behind NIRS technology, relationship of c-rSO2 to other brain monitoring values and their potential clinical interpretation. We follow with a critical evaluation of the use of NIRS in the aSAH population, more specifically its ability to diagnose vasospasm, to predict DCI and its association to outcome. In summary, NIRS might offer significant potential for poor grade aSAH in the future. However, current evidence does not support its use in clinical decision-making, and proper technology evaluation is required.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, QC, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
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Sivilotti MLA. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016; 81:428-36. [PMID: 26469689 PMCID: PMC4767210 DOI: 10.1111/bcp.12731] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 01/14/2023] Open
Abstract
Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.
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Affiliation(s)
- Marco L A Sivilotti
- Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Ontario, Canada
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Penninga EI, Graudal N, Ladekarl MB, Jürgens G. Adverse Events Associated with Flumazenil Treatment for the Management of Suspected Benzodiazepine Intoxication - A Systematic Review with Meta-Analyses of Randomised Trials. Basic Clin Pharmacol Toxicol 2015; 118:37-44. [DOI: 10.1111/bcpt.12434] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/15/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Elisabeth I Penninga
- Department of Medicines Licensing and Availability; Danish Health and Medicines Authority; Copenhagen Denmark
- Danish Poison Information Centre; Bispebjerg University Hospital; Copenhagen Denmark
| | - Niels Graudal
- Department of Rheumatology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Morten Baekbo Ladekarl
- Danish Poison Information Centre; Bispebjerg University Hospital; Copenhagen Denmark
- Department of Radiology; Roskilde University Hospital; Roskilde Denmark
| | - Gesche Jürgens
- Danish Poison Information Centre; Bispebjerg University Hospital; Copenhagen Denmark
- Unit of Clinical Pharmacology; Roskilde University Hospital; Roskilde Denmark
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Kreshak AA, Cantrell FL, Clark RF, Tomaszewski CA. A Poison Center's Ten-year Experience with Flumazenil Administration to Acutely Poisoned Adults. J Emerg Med 2012; 43:677-82. [DOI: 10.1016/j.jemermed.2012.01.059] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 08/16/2011] [Accepted: 01/16/2012] [Indexed: 11/29/2022]
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Lund C, Drottning P, Stiksrud B, Vahabi J, Lyngra M, Ekeberg I, Jacobsen D, Hovda KE. A one-year observational study of all hospitalized acute poisonings in Oslo: complications, treatment and sequelae. Scand J Trauma Resusc Emerg Med 2012; 20:49. [PMID: 22828054 PMCID: PMC3413541 DOI: 10.1186/1757-7241-20-49] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/24/2012] [Indexed: 11/17/2022] Open
Abstract
Objectives Changes in poisoning trends may affect both complications and outcomes in patients with acute poisoning. This study reports the treatments given and the frequency of complications, also related to treatment, mortality and sequelae related to various toxic agents. Methods All acute poisonings in adults (≥16 years) admitted to the five hospitals in Oslo were included consecutively during one year (2008 to 2009) in an observational cross-sectional multicenter study. A standardized form was completed by the treating physician, which covered the study aims. Results There were 1065 admissions in 912 patients. The median length of hospital stay was one day, and 49% were observed in an intensive care unit (ICU). Active treatment was given to 83%, and consisted of supportive therapy (70%), antidote(s) (38%), activated charcoal (16%) and gastric lavage (9%). The most commonly used antidotes were flumazenil (19%), naloxone (17%) and N-acetylcysteine (11%). The rate of treatment-related complications was 2.4% (21/884). Neither flumazenil, naloxone, nor the combination, was associated with convulsions or other complications. Among those receiving N-acetylcysteine, 5% (6/120) developed allergic reactions, one of which mandated discontinuation of treatment. Nineteen percent presented in a coma. Complications developed in 30%, compared with 18% in a 2003 study, mainly respiratory depression (12%), prolonged QTc interval (6%) and hypotension (5%). Eight patients died (0.8%) and five (0.5%) survived with permanent sequelae, mainly anoxic brain damage. Discussion Few patients stayed more than two days. The use of the ICU was liberal, considering that only one out of five presented in a coma. Antidotes were frequently given diagnostically. Although N-acetylcysteine induced allergic reactions, most were mild and treatment discontinuation was only necessary once. The frequency of complications had almost doubled in five years, although the poisoning pattern was largely unchanged. However, few patients developed permanent sequelae.
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Affiliation(s)
- Cathrine Lund
- Department of Acute Medicine, Oslo University Hospital Ullevaal, Kirkeveien 166, Oslo (0407), Norway
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Heyerdahl F, Bjornas M, Hovda KE, Skog K, Opdahl A, Wium C, Ekeberg O, Jacobsen D. Acute poisonings treated in hospitals in Oslo: A one-year prospective study (II): Clinical outcome. Clin Toxicol (Phila) 2010. [DOI: 10.3109/15563650701210048] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Oray NC, Hocaoglu N, Oray D, Demir O, Atilla R, Tuncok Y. Sedative-Hypnotic Medication Exposures and Poisonings in Izmir, Turkey*. Basic Clin Pharmacol Toxicol 2008; 103:380-5. [DOI: 10.1111/j.1742-7843.2008.00303.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249-81; abstract vii. [PMID: 17482020 DOI: 10.1016/j.emc.2007.02.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Toxic overdose can present with various clinical signs and symptoms. These may be the only clues to diagnosis when the cause of toxicity is unknown at the time of initial assessment. The prognosis and clinical course of recovery of a patient poisoned by a specific agent depends largely on the quality of care delivered within the first few hours in the emergency setting. Usually the drug or toxin can be quickly identified by a careful history, a directed physical examination, and commonly available laboratory tests. Once the patient has been stabilized, the physician must consider how to minimize the bioavailability of toxin not yet absorbed, which antidotes (if any) to administer, and if other measures to enhance elimination are necessary.
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Affiliation(s)
- Timothy B Erickson
- Department of Emergency Medicine, Division of Clinical Toxicology, University of Illinois at Chicago, Toxikon Consortium, Chicago, IL 60612, USA.
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Ngo ASY, Anthony CR, Samuel M, Wong E, Ponampalam R. Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department? Resuscitation 2007; 74:27-37. [PMID: 17306436 DOI: 10.1016/j.resuscitation.2006.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 11/01/2006] [Accepted: 11/08/2006] [Indexed: 11/16/2022]
Abstract
UNLABELLED Patients in coma with suspected drug poisoning are commonly encountered in the emergency department. Benzodiazepines are one of the most commonly used drugs in self-poisoning. Flumazenil, a benzodiazepine antagonist has been suggested as a diagnostic and treatment tool in suspected poisoning of unclear cause, but caution is required due to potential side effects. No systemic review of this literature has been done on this topic. OBJECTIVES The aim of this study is to examine if flumazenil should be used in patients with coma from suspected drug poisoning. SEARCH STRATEGY Randomised controlled trials were identified from the Cochrane Library, Pubmed and EMBASE. Bibliographies from included studies, known reviews and texts were searched. Content experts were contacted. SELECTION CRITERIA Randomised controlled trials were eligible for inclusion. Studies were included if patients who presented with altered mental state from suspected drug poisoning were treated with intravenous flumazenil as compared to placebo. DATA COLLECTION AND ANALYSIS Data were extracted and methodological quality was assessed independently by two reviewers. MAIN RESULTS Seven randomised controlled trials were included. A total of 466 patients were involved. Flumazenil was found to reverse coma from suspected drug poisoning with a relative benefit of 4.45 (95% CI 2.65, 7.45). In terms of major side effects, there was no statistical difference between flumazenil and placebo (RR 2.86, 95% CI 0.12-69.32). However, in terms of minor side effects, flumazenil was associated with a higher incidence of anxiety (RR 2.84, 95% CI 1.28-6.30) and other side effects (RR 3.73, 95% CI 2.078-6.73). There was no difference in the incidence of vomiting (RR 4.28, 95% CI 0.95-19.35). CONCLUSION Current evidence shows that flumazenil may be effective in the reversal of coma in patients presenting to the emergency department with coma from suspected drug poisoning.
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Affiliation(s)
- Adeline Su-Yin Ngo
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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Abstract
Flumazenil is frequently administered to the poisoned patient. Seizures may be precipitated and resedation may occur in patients who awakened following flumazenil administration. Seizures may increase morbidity and mortality of the overdose. Benefit:Risk ratio of administering flumazenil should be determined in each overdose patient. Indications for flumazenil are limited.
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Affiliation(s)
- Donna L Seger
- Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
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Huen MSY, Leung JWC, Ng W, Lui WS, Chan MNS, Wong JTF, Xue H. 5,7-Dihydroxy-6-methoxyflavone, a benzodiazepine site ligand isolated from Scutellaria baicalensis Georgi, with selective antagonistic properties. Biochem Pharmacol 2003; 66:125-32. [PMID: 12818372 DOI: 10.1016/s0006-2952(03)00233-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
As part of an effort to identify naturally occurring GABA(A) receptor benzodiazepine binding site (BDS) ligands from traditional medicinal herbs, we previously reported that flavonoid derivatives isolated from Scutellaria baicalensis (S. baicalensis) Georgi exhibited significant affinities for the BDS. The present study describes the characterization of 5,7-dihydroxy-6-methoxyflavone (oroxylin A), one of the major components of the herbal extract. Oroxylin A inhibited [3H]flunitrazepam binding to rat cerebral cortical membrane with a IC(50) value of 1.09+/-0.07 microM. A GABA ratio of 1.09+/-0.04 suggests that oroxylin A interacts as an antagonist at the recognition site. In neuropharmacological studies, oral administration of oroxylin A (3.75-60 mg kg(-1)) did not result in significant changes in animal models routinely employed for benzodiazepine (BD) evaluation. However, oroxylin A selectively abolished the anxiolytic, myorelaxant and motor incoordination, but not the sedative and anticonvulsant effects elicited by diazepam, a BDS agonist. These results add oroxylin A to the list of CNS active flavonoids, and as the first naturally occurring member endowed with selective antagonistic actions via the BDS.
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Affiliation(s)
- Michael S Y Huen
- Department of Biochemistry, Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
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Abstract
We report the case of a 63-year-old man who presented to the Emergency Department (ED) with a 1-week history of sore throat, hoarseness and dysphagia. During his ED workup, the patient experienced an acute delirium 25 min after being given 2 mg of Lorazepam. The patient's mentation returned to normal within 1-2 min of being given 1 mg of Flumazenil. We discuss the various behavioral side effects of benzodiazepines and the indications for the use of Flumazenil.
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Mokhlesi B, Leiken JB, Murray P, Corbridge TC. Adult toxicology in critical care: part I: general approach to the intoxicated patient. Chest 2003; 123:577-92. [PMID: 12576382 DOI: 10.1378/chest.123.2.577] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Intensivists are confronted with poisoned patients on a routine basis, with clinical scenarios ranging from known drug overdose or toxic exposure, illicit drug use, suicide attempt, or accidental exposure. In addition, drug toxicity can also manifest in hospitalized patients from inappropriate dosing and drug interactions. In this review article, we describe the epidemiology of poisoning in the United States, review physical examination findings and laboratory data that may aid the intensivist in recognizing a toxidrome (symptom complex of specific poisoning) or specific poisoning, and describe a rational and systematic approach to the poisoned patient. It is important to recognize that there is a paucity of evidence-based information on the management of poisoned patient. However, the most current recommendations by the American Academy of Clinical Toxicology and European Association of Poisons Centers and Clinical Toxicologists will be reviewed. Specific poisonings will be reviewed in the second section of these review articles.
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Affiliation(s)
- Babak Mokhlesi
- Division of Pulmonary and Critical Care Medicine, Cook County Hospital/Rush Medical College, Chicago, IL 60612, USA.
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Mathieu-Nolf M, Babé MA, Coquelle-Couplet V, Billaut C, Nisse P, Mathieu D. Flumazenil use in an emergency department: a survey. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 39:15-20. [PMID: 11327221 DOI: 10.1081/clt-100102874] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the efficacy of flumazenil use by a one-year survey of practice in tan emergency department. DESIGN During a one-year period, an observational prospective study in the emergency department of an urban community hospital enrolled every patient admitted with a history of pure or mixed benzodiazepine acute poisoning. Case records were secondarily reviewed by an expert group. Actual flumazenil use during hospitalization was compared to currently recommended indications. In order to evaluate the efficacy of flumazenil use, patients who received flumazenil were matched with those who did not and effects on mortality, morbidity, number of costly procedures (CT scan, diagnostic toxicology, etc.) and duration of hospital stay were determined. RESULTS Of the 1529 patients admitted in 1 year for acute poisoning, 478 reportedly ingested at least one benzodiazepine. Twenty-nine patients (6%) received flumazenil in the emergency department whereas the expert reviewers recommended flumazenil use in only 18 (3.7%). In 11/29 (38%) cases, the use of fumazenil was considered inappropriate. The expert group considered flumazenil to be contraindicated in 93 of 478 patients. Nonetheless, flumazenil was used in 11 patients (rate of potentially harmful flumazenil use: 11/93; 12%), and a severe complication occurred in one of these patients after flumazenil. No significant difference could be shown in outcome, complication rate, number of complex procedures or duration of hospital stay between patients who received flumazenil and matched patients who did not. CONCLUSION The use of flumazenil in the clinical practice of an emergency department fails to show any beneficial effect in adult patients. Moreover, contraindications are frequently overlooked and this may expose patients to substantial risk of complications.
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Affiliation(s)
- M Mathieu-Nolf
- Northern France Poison Center, Regional University Hospital, Lille, France.
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Flumazed. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2000. [DOI: 10.1016/s1522-8401(00)90033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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