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Key Features

  • Sedative-hypnotics depress the CNS reticular activating system, cerebral cortex, and cerebellum

Clinical Findings

  • Mild intoxication produces euphoria, slurred speech, ataxia, and even hypoglycemia

  • Severe intoxication produces stupor, coma, bradycardia, hypotension, hypothermia, and respiratory arrest

  • Death is usually due to pulmonary aspiration of gastric contents

  • Massively intoxicated patients may appear dead, with no reflex responses or even electroencephalographic activity

Diagnosis

  • Ethanol serum levels > 300 mg/dL (0.3 g/dL; 65 mmol/L) usually produce coma in a novice user, but regular users may remain awake at much higher levels

  • Many agents not detected on urine toxicology screening

Treatment

  • Activated charcoal

    • Administer 60–100 g orally or via gastric tube, mixed in aqueous slurry if given within 1 h of ingestion

    • Use when the patient has ingested a massive dose and the patient has been intubated to protect the airway

  • Hemodialysis may be necessary for severe phenobarbital intoxication

  • Flumazenil is a specific benzodiazepine antagonist and has no effect on ethanol, barbiturates, other sedative-hypnotic agents

    • Consider flumazenil, 0.2 mg over 30–60 seconds intravenously, repeated in 0.2–0.5 mg increments as needed up to a total dose of 3–5 mg

    • Caution: Flumazenil should rarely be used because it may induce seizures in patients with preexisting seizure disorder, benzodiazepine addiction, or concomitant overdose with tricyclic antidepressants or other convulsant

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