Please help, important OD question.

[vanelo]

Hi all!

I have a doubt, does flumanezil antagonizes the effects of zolpidem (Ambien) in cases of OD's?

Thanks for any help.

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[edinOH]

Good question (not so good english).

Ambien "works" on the BZD receptor, just on a site different than the usual suspects such as ativan, valium, etc. Too lazy to look up the specifics now.

Worth a shot I guess.

My gut tells me it would work.

I trust my gut. It is big.

Otherwise, dial 1-800-POISONCONTROL.

 

[Wahoo]

Flumazenil does purportedly antagonize the sedative/hypnotic effect of Ambien.

 

[Sessamoid]

Doesn't really matter for us, because I'm never going to give flumazenil for a comatose patient who is suffering from an intentional overdose. Even an accidental overdose of ambien probably won't be treated with flumazenil, assuming it works. Last thing I need is a patient in status that can't be treated with benzos, so the nurses have to futzing around trying to find IV phenobarb or propofol.

 

[Wahoo]

Hey Sessamoid, good point.

I have a potentially stupid question, however. Having just finished my first year of med school means I'm still allowed to ask stupid questions, I think...

Since the Benzo dose-response curve levels off at high doses and does not cause death/respiratory depression like barbituates, couldn't you just give an extra large dose of benzo's to a patient that goes into status who's been given flumazenil previously (essentially trying to out-compete the antagonist)? Clearly it'd be better to avoid the situation in the first place, but I'm just posing a hypothetical here... What would be the consequence?


(It's the last summer off of my life, I don't know what the heck I'm doing here asking questions...)

 

[Sessamoid]

Hey Sessamoid, good point.

I have a potentially stupid question, however. Having just finished my first year of med school means I'm still allowed to ask stupid questions, I think...

Since the Benzo dose-response curve levels off at high doses and does not cause death/respiratory depression like barbituates, couldn't you just give an extra large dose of benzo's to a patient that goes into status who's been given flumazenil previously (essentially trying to out-compete the antagonist)? Clearly it'd be better to avoid the situation in the first place, but I'm just posing a hypothetical here... What would be the consequence?


(It's the last summer off of my life, I don't know what the heck I'm doing here asking questions...)

Sure, IIRC it's a competitive antagonist, so you could overcome it with massive doses. The problem being that you may not have massive doses immediately available to you. The concern isn't just rebound seizures in a chronic user, but the possibility of co-ingestion of another medication that could cause seizures. I did note a few case reports of a suicide with nothing on-board except zolpidem, so it may not be as safe in isolated overdose as traditional benzodiazepines. At my little community hospital, I've emptied the Pyxis of morphine (annoying) and a couple other meds during busy shifts. I emptied the Pyxis at the county hospital where I did my residency treating delirium tremens (my protocol is doubling Ativan doses until stable, i.e. 2 mg -> 4 mg -> 8 mg, etc. I got up to 32 mg at once). They had to go to pharmacy to get enough for that last dose.

You can't be sure in the acute situation what else the patient may have taken. The standard of care would be to intubate and mechanically ventilate, essentially supportive care until the sedatives have worn off.

 

[DocWagner]

I am proud to say...I may be the only one on this board who has ever used Flumazenil in unknown injestion.
It saved the patients life. This will likely become a case reported study at some point.

In my case, I had a patient with known dose of ativan...family did NOT want intubation...uncompensated respiratory acidosis (when I found out the respiratory sedation effects of benzos were stronger than the body's compensatory effects). Didn't have much of a choice...seize and die...or die from not trying and just waiting.

Flumazenil can be given in BABY doses (.2mg starting up to 3mg total)...you WILL see a response with .2mg if you see anything at all.
Sometimes you have to just DO IT.

 

[mikecwru]

Was this a person with a DNR? How can a family refuse intubation on person who would be competent to make decisions but is unconscious? Wouldn't you just say "FU" and intubate them?

mike

I am proud to say...I may be the only one on this board who has ever used Flumazenil in unknown injestion.
It saved the patients life. This will likely become a case reported study at some point.

In my case, I had a patient with known dose of ativan...family did NOT want intubation...uncompensated respiratory acidosis (when I found out the respiratory sedation effects of benzos were stronger than the body's compensatory effects). Didn't have much of a choice...seize and die...or die from not trying and just waiting.

Flumazenil can be given in BABY doses (.2mg starting up to 3mg total)...you WILL see a response with .2mg if you see anything at all.
Sometimes you have to just DO IT.

 

[DocWagner]

Sorry...patient made clear wishes to family to NOT intubate, yet provide medical care. All family concurred with this request. But she was NOT a DNR.

 

[DrQuinn]

wow. cool case. i've never been in a situation where i've needed flumazenil. I've had some attendings who have never ever used it in their entire career.

Speaking of flumazenil and other things we dont' normally use, any of you out there read any IVPs? We do straight CT stone searches, but I want to atleast see an IVP or two before I'm done.

I am SO hung over its not even funny. Atleast I'm not a PGY-1 who has ATLS today. Hahhaahh.

Q< DO

 

[DocWagner]

Yep, read lots of IVP's...delayed filling etc...scout film stones...
I am not an expert, but I do an ok job. CT's are much easier.

 

[slackerjock]

(It's the last summer off of my life, I don't know what the heck I'm doing here asking questions...)

wahoo, nah, this aint the last summer of your life. granted your next summer will be pure hell, but you'll have 1-3 months off before residency. during any residency, you'll have 3-4 weeks off per year. and we all know about the derm lifestyle, which explains what you're doing here asking questions

 

[Sessamoid]

When I was in residency, the hospital was just switching over from IVPs to CT urograms, so I read a fair number of IVPs in residency. After residency, there was one urologist who strongly preferred IVPs, so I ended up doing them when he was on call or on his patients. I haven't read an IVP in at least a year now, though.