Multiple Drug O/D

[rdelisle]

Hi all. Ran a call last night where the Pt. had O/D'd on multiple drugs. Pt. was Unconscious and Unresponsive O/A. O/E pt resp 10 and shallow BP 130/80, O2 Sat's 96%Ra, Pupils 4mm and very sluggish, Pulse 136 and weak. Hx. pt. had swallowed an unknown number of Temazepam, Bromazepam and Seraquil. Pt had also snorted approx. 10 temazepam. TX was NPA, O2@10lpm via NRB, IV. NS. KVO. cardiac monitoring and rapid transport. As a PCP that is the limit of my scope in this type of call. Also had the Pt. secured to a spine board in case of vomiting or waking up combative. I have two questions, what if anything else could I have done, and what is the general outcome of combination Benzo/SSRI ODs?

[Asysin2leads]

Well, some services carry Flumazenil, but according to an ER doc I chatted with, the dangers of using it outweigh the benefits of giving it in the field. I suppose you could try giving a rapid infusion of NS 0.9% to try and "dilute" the drug, but that theory to me has always been a bit dubious, only because while I may have fallen asleep during a few A&P lectures, I did do fairly well in chemistry. Blood is a colloid, with some stuff dissolved in it and some stuff not dissolved. Now, you could decrease the concentration of a drug by adding more solution, but if you actually did give enough NS to appreciably dilute the blood (If the human body has 5 liters of blood, then to decrease the drug concentration by 50% you'd have to give 5 liters of NS) and overcame the bodies homeostatic measures to maintain blood solute concentration, you'd also decrease the concentration of all the other stuff in the blood, such as RBC's, platelets, WBC's, and so on, not to mention increasing the intravascular pressure to the point where you'd probably end up with pulmonary edema and a whole host of other stuff, which is probably a lot worse than having too much drug in you.

So really, all you can do is supportive measures. Maintain airway, monitor pulse rate and BP, be wary of vomit and aspiration, etc. etc. etc.

[chbare]

Rdelisle, that is about all you can do. Even in the hospital we would run a battery of tests, consider intubation, and let them sleep if off in the ICU. As Asysin2leads stated, reversing Benzos in the field can be quite dangerous. It sounds like this patient may be on chronic benzo therapy. With chronic therapy the body can develop a tolerance and dependance upon benzos. If you were to suddenly try to reverse benzos, you could inavertantly cause withdrawl. If the patient develops seizures you will be hard pressed to stop the seizures because the primary agents for seizures are benzos.

Take care,

chbare.

[Spock]

I couldn't agree more with the comments regarding flumazenil. The only other thing I would have done was check a blood sugar because seroquil can cause severe hyperglcemia and hypoglycemia should always be ruled out in an unconscious patient. I probablywould have given narcan on the off chance the patient took an opioid that was unreported. Also, I would have intubated the patient as long as the teeth were not clenched. GCS < 8 means unable to protect the airway and intubation is indicated. However, I wouldn't argue with the treatment provided especially since you were vigilant about the chance for aspiration from vomiting. I'm not familiar with a PCP. Are you allowed to intubate?

Live long and prosper.

Spock

[AZCEP]

Consider an NPA, and some sugar. Let them sleep it off in a monitored setting.

[northernmedic]

Flumazenil....bad.

Very few people actually die from a benzo overdose. The biggest concern is protecting the airway and sometimes hypotension depending on the dose. Sounds like you basically managed both of those. Seroquel can cause hypertension and tachycardia as well as some rigidity and other neurologic sequelae so it may have actually helped to prevent some benzo related hypotension.

[NREMT-Basic]

While I understand that you could be hard-pressed to stop benzo withdrawal seizures in the field, thought it sounds counter-intuitive, would not a small loading dose of ativan do it. Yes I know it is another benzo, but if you worry is stopping the seizure, this seems like a way to do it. And actually, according to the National Poison Control Center, Benzo overdose is a significant factor in either intentional or accidental overdose related death. But then, as I am told so often, I am only a Basic/D and would be happy to hear what others have to say.

[AZCEP]

Benzodiazepines can kill, but more frequently it is the respiratory depression that does the job.

The therapeutic index of most BZD's make them some of the safest drugs ever devised. Trouble is, you take some BZD, it only makes you sleepy, then you throw in some Tylenol, then maybe some TCA, then maybe some opioid, then top it all off with some alcohol. The combination kills you, not any one agent, and the others are much more lethal.

Ativan will be of limited help following use of Romazicon. You've bound the BZD receptor with an antagonist, so more BZD won't be effective until the antagonist wears off. If the standard dose, without the antagonist is 1 mg, you will need significantly more to get a therapeutic benefit. Then the dangers come up again.

[kitkat]

PCP=Primary Care Paramedic= No intubations

According to NOCP=National Occupational Competency Profiles

PCP are only required to have an awareness or the practitioner must have demonstrated an academic understanding of the competency. Individual evaluation is required.

it would be under Area 5 therapeutics-5.1.f, 5.1.g,5.1.h

You can check it out on the Paramedic of Canada website. (PAC)

hope that helps

[bassnmedic]

The effects and half life of the Romazicon are very much longer than the benzos and therefore the amount of Ativan needed to counteract the Romazicon would be far more detrimental. Azcep I think is dead on with his posts.