Sedative Toxidrome
AGENTS
- opioids
- benzodiazepines
- barbiturates
- baclofen (may mimic brain death, suspect in MS patients)
- clonidine (mimics opioid toxidrome with marked bradycardia and hypotension)
- GHB
CLINICAL FEATURES
- sedation
- coma
- pupillary changes
- respiratory and cardiovascular depression
INVESTIGATIONS
- urine drug screen – not useful acutely, many drawbacks
SPECIFIC MANAGEMENT AND TRIGGERS FOR INTERVENTION
Opioids
- naloxone: titrated doses until reversal of respiratory depression -> may require an infusion
- dose: 0.04-2mg IV/IM/SC/ INH/IN -> 1-10mcg/kg/hr
- best to give in small increments while providing respiratory support
Barbiturates
- supportive care
- multiple doses of activated charcoal
- alkaline diuresis
- haemoperfusion
Benzodiazepines
- supportive care
- avoid flumazenil if possible – may precipitate withdrawal or intractable seizures
- consider flumazenil in pediatric ingestion or if benzodiazepines were administered for procedural sedation
- flumazenil: titrated doses until reversal of respiratory depression -> may require an infusion
- dose: 0.2mg IV -> 0.1-0.4mg/hr
Clonidine
- supportive care
- trial naloxone
GHB
- supportive care
- coma should resolve <6 hours, unless diagnosis wrong or re-ingestion!
Baclofen
- supportive care
- like barbiturates, may mimic brain death
References and Links
- Tox Conundrum – Alprazoslammed
- Tox Conundrum – Brain Dead?
- Tox Conundrum – Two Pills can Kill
- Tox Conundrum – A Toxic Slumber
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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