Title Management of acute benzodiazepine intoxication and withdrawal in the Emergency department setting Title (croatian) Obrada i liječenje akutnog otrovanja benzodijazepinima i njihovog sustezanja u Odjelu hitne medicine Author Karlo Matić Mentor Vesna Degoricija (mentor)Committee member Vesna Degoricija (predsjednik povjerenstva)Committee member Jasenka Markeljević (član povjerenstva)Committee member Ivan Gornik (član povjerenstva)Granter University of Zagreb Defense date and country 2019-07-12, Croatia Scientific / art field, BIOMEDICINE AND HEALTHCARE Scientific / art field, BIOMEDICINE AND HEALTHCARE Abstract 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.
Abstract (croatian) U zadnjih nekoliko desetljeća vidi se porast u propisivanju i zloupotrebi benzodiazepina (BZDs). Zbog ovoga, vidi se porast posjeta hitne službe uslijed trovanjem droge s benzodiazepinima i odvikavanjem droge. Rizične skupine su starije osobe, trudnice, djeca i osobe s poremećajima mentalnog zdravlja. Iako nijedna od ovih slučajeva nije tipično smrtonosna u samom korištenju BZD-a, zabilježeni su smtni slučajevi, zajedno s velikim brojem smtrnih slučajeva koji uključuju kombiniranu intoksikaciju lijekovima s BZD-om. Prikaz izoliranih intoksikacija s BZD-ima varira od pacijenta do pacijenta, ali uključuje suzbijanje središnjeg živčanog sustava, koji dovodi do simptoma kao što su nerazgovjetni govor, dvostruki vid, nistagmus, ataksija, anterogradna amnezija, problem s ravnotežom/koordinacijom, respiratorna depresija i sedacija. Komatozni pacijenti su kod visokog rizika od aspiracijske pneumonije, i razvoju komplikacija kao rabdomiloze. Liječene intoksikacije BZD-om obično se provodi putem potporne skrbi i flumazenilom (antagonist BZD-a) kada se zadovolje odreĎene kriterije. Nedavni podaci u medicinskoj zajednici su pokazali da je uporaba flumazenila ograničena i može uzrokovati više štete nego koristi, zbog rizika od epileptičkog napada i simptoma odvikavanja. Odvikavanje BZD-a iskazuje se nakon prestanka ili smanjenja uporabe BZD-a nakon produžene ili visoke doze izloženosti. Pacijenti predstavljaju s autonomnom hiperaktivnošću, taktilnim/visualnim halucinacijama, anksioznošću, nesanicom, mučninom/povraćanjem, tremorom ruke i mogućim grand-mal epileptičkim napadajima. Liječenje odvikavanja BZD-a obično se postiže korištenjem BZD-a i primjenom uprave sužavanja lijeka (BZD-a) kako bi učinkovito smanjili simptome tijekom vremena. Prethodna istraživanja su predložili da se flumazenil može koristiti za liječenje odvikavanja BZD-a jer su pacijenti koji su dodali flumazenil u upravu sužavanja lijeka pokazali veću uspješnost u usporedbi sa skupinom pacijenta koje su primale placebo. Kako je upotreba flumazenila obično rezervirana za pacijente s teškom respiratornom depresijom, sedacijom, izoliranom BZD-skom intoksikacijom i pacijentima koji ne uzimaju prokonvulzivne lijekove, uporaba ovog antagonista BZD-a je vrlo ograničena. Zbog toga se pokazalo da je liječenje intoksikacije i odvikavanje BZD-a teško, buduči da nema dovoljno značajnih podataka za ispunjavanje kriterija za uporabu flumazenila. Cilj smanjenja intoksikacije i simptoma odvikavanja BZD-a trebali bi biti usmjereni osnovnoj prevenciji. Iako bi uporaba benzodiazepina trebala biti ograničena na 2-4 tjedna, mnogi liječnici primarne zdrastvene zaštite i dalje propisuju BZD-e pacijentima za kroničnu upotrebu. Konačno, to dovodi do povećanja broja pacijenata koji zloupotrebljavaju BZD-e i stoga su izloženi riziku intoksikacije i simptoma odvikavanja BZD-a.
Keywords
benzodiazepine
emergency department
drug intoxication
withdrawal
flumazenil
Keywords (croatian)
benzodiazepina
hitna služba
trovanje drogom
odvikavanje
flumazenil
Language english URN:NBN urn:nbn:hr:105:345681 Study programme Title: Medicine (in English language) Type of resource Text File origin Born digital Access conditions Open access Terms of use Created on 2020-07-22 10:05:27
