A 23-year-old male weight-lifter with no significant past medical history is brought to the ED after having a seizure at the gym. Upon ED arrival, you note the patient is agitated and is demanding to be released. On examination, he is a well-developed man who appears diaphoretic, restless, and hyper-vigilant. His vital signs are: blood pressure, 180/80 mm Hg; respiratory rate, 16 breaths/ min; pulse, 125 beats/min; room-air pulse oximetry, 100%; and temperature 39.2°C (102.5°F). He is alert and oriented to person, place, and time. His pupils are 5 mm and equally reactive to light, and he has a resting tremor. He has normal breath sounds on auscultation of his chest wall, and his skin is diaphoretic. A friend arrives shortly after the patient’s arrival to the ED and states that the patient had been drinking "blue something" over the course of the past year and had run out of it earlier that morning. You wonder if the drink and the seizure could be related...
A 40-year-old obese woman is brought to the ED by EMS after being found wandering on the street on a warm day. She has a past medical history significant for anxiety and takes alprazolam chronically. On examination, she is soiled in her own feces and vomit, is diaphoretic, combative, altered, groaning incoherently, and unable to follow commands. You administer haloperidol for her agitation. Her vital signs are: blood pressure, 210/105 mm Hg; respiratory rate, 32 breaths/min; room-air pulse oximetry, 84%; and temperature, 40°C (104.1°F). Shortly after she arrives, she has a generalized tonic-clonic seizure. You wonder whether the haloperidol might have made her symptoms worse and what other agents you should use...
A 25-year-old intubated patient diagnosed with clonazepam withdrawal is boarding in your ED, awaiting an ICU bed. He is receiving fentanyl and propofol infusions. The nurse alerts you that his heart rate is in the 130s and his blood pressure is 190/100 mm Hg. You are worried about his vital signs, but you are not sure what to do about it...
As the prescription drug abuse crisis reaches epidemic proportions in the United States,1,2 so are the numbers of emergency department (ED) patients suffering from sedative-hypnotic drug withdrawal.3 According to 2011 data from the Drug Abuse Warning Network (DAWN), sedative-hypnotic agents were the second most frequently reported drug class to cause an ED visit. (Opioids were the most frequent cause.) Of drug-related ED visits, benzodiazepines accounted for 28.7%, and sedative-hypnotics in general accounted for 34%. (See Table 1 for a partial listing of sedative-hypnotic and related drugs by class, with chemical and common brand names.) From 2004 to 2011, ED visits due to use of oxycodone and alprazolam increased 263% and 166%, respectively.3 Many of these ED visits also involved co-ingestions with other drugs, concurrent illnesses, motor vehicle crashes, or other types of trauma.
There is a growing body of literature on sedative- hypnotic withdrawal that attempts to identify the best management strategies. Benzodiazepines are, classically, the first-line agents in managing withdrawal syndromes; however, there are other adjunct medications available that have good supporting evidence. Treating these patients can be improved by following a step-wise, patient-specific approach that requires an understanding of the particular pathophysiology of sedative-hypnotic withdrawal. This issue of Emergency Medicine Practice reviews the pathophysiology, general approach, diagnostic decision-making tools, pharmaceutical treatment options, and disposition criteria to help emergency clinicians create a patient-tailored approach to sedative-hypnotic withdrawal.
A PubMed and Cochrane Database of Systematic Reviews search was performed for articles published between 1980 and 2016 using the search terms sedativehypnotic withdrawal, GABA, benzodiazepine, barbiturate, baclofen, GHB, GBL, ethanol, and emergency department. A total of 2873 articles were identified, of which, 83 were used for this review. The majority of the guidelines and recommendations regarding the treatment of withdrawal symptoms from gamma-Aminobutyric acid (GABA)ergic agents have come from literature on ethanol withdrawal. By contrast, the majority of the literature regarding withdrawal symptoms from GABAergic agents such as benzodiazepines, barbiturates, baclofen, gamma-Hydroxybutyric acid [GHB], and gamma-Butyrolactone (GBL) are case reports and retrospective studies. There is a paucity of randomized prospective studies or clinical trials for these individual GABAergic agents, and the majority of the guidelines are derived from expert consensus opinion and literature reviews.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Welcome back to another episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. This month, we’ll be talking about sedative-hypnotics. Specifically, we’ll be talking about sedative-hypnotic drug withdrawal syndromes, both the recognition of such syndromes and their appropriate treatment.
This episode’s content was curated by Cynthia Santos, MD, of Emory University Hospital and Ruben Olmedo, MD, who is director of the division of toxicology at Mount Sinai Hospital. Don’t miss it!
Links and Resources:
Sedative-Hypnotic Drug Withdrawal Syndrome: Recognition And Treatment – http://bit.ly/2mp4mAR
Alcohol Withdrawal Syndrome: Improving Outcomes Through Early Identification And Aggressive Treatment Strategies (Critical Care Issue) – http://bit.ly/2mWN8hp
Current Guidelines For The Management Of Acute Alcohol Withdrawal In The Emergency Department – http://bit.ly/2nkBM7H
Emory University Hospital - https://www.emoryhealthcare.org/locations/hospitals/emory-university-hospital/
Mount Sinai Hospital - http://www.mountsinai.org/locations/mount-sinai
16th Annual Clinical Decision Making in Emergency Medicine - http://clinicaldecisionmaking.com/
Hosts: Nachi Gupta, MD, PhD; Jeff Nusbaum, MD
Cynthia Santos, MD; Ruben E. Olmedo, MD
March 1, 2017
March 31, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits
Upon competion of this article, you should be able to:
Date of Original Release: March 1, 2017. Date of most recent review: February 10, 2017. Termination date: March 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2016. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Santos, Dr. Olmedo, Dr. Carlson, Dr. Tuckler, Dr. Mishler, Dr. Toscano, Dr. Jagoda, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
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