II. Class

III. Preparations: Medical Uses

IV. Precautions: Fake Xanax

  1. Fake Xanax contains Fentanyl and Etizolam (Benzodiazepine analog)
  2. Presents as opiod Overdose with sedation and respiratory depression (Rhabdomyolysis was also associated)
  3. Management
    1. Naloxone 0.4 mg
    2. Supportive care
    3. Consult poison control
  4. References
    1. Swadron and Nordt in Herbert (2017) EM:Rap 17(2):18
    2. ThePoisonReview.com
      1. http://www.thepoisonreview.com/2016/08/24/case-series-8-patients-exposed-to-phony-alprazolam-xanax-containing-fentanyl-andor-etizolam/

V. Symptoms: Benzodiazepine Withdrawal

  1. Anxiety
  2. Insomnia
  3. Myalgias
  4. Tremors
  5. Seizures

VI. Signs: BenzodiazepineIntoxication

  1. Classic presentation is Altered Level of Consciousness with normal Vital Signs
  2. Cardiopulmonary effects
    1. Respiratory Depression (esp. when combined with other substances, e.g. Alcohol)
    2. Hypotension
    3. Rarely lethal alone, but dangerous with Alcohol
  3. Neurologic effects
    1. Anterograde Amnesia
    2. Ataxia (esp. young children)
    3. Confusion
    4. Slurred Speech
    5. Miosis
  4. Spectrum of Decreased Level of Consciousness
    1. Drowsiness
    2. Lethargy
    3. Sedation
    4. Coma

VII. Differential Diagnosis

  1. See Unknown Ingestion
  2. May present in similar fashion to Diabetic Ketoacidosis

VIII. Management: Toxicity

  1. Benzodiazepines Overdoses in isolation generally have good outcomes
    1. CNS Depression (and apnea) increases when combined with other agents (e.g. Opioids)
    2. Coingestion is common
  2. Supportive care with airway management for CNS Depression
  3. Flumazenil (Romazicon)
    1. Avoid in patients with chronic use (risks of severe withdrawal including Seizures)
      1. Most toxicology guidelines do not recommend Flumazenil in Overdose
      2. Potential harms appear to outweigh benefits in most cases
      3. Penningo (2016) Basic Clin Pharmacol Toxicol 118(1): 37-44 +PMID:26096314 [PubMed]
    2. May be indicated for acute Benzodiazepine Overdose (non-chronic use) with cardiopulmonary depression
    3. Read Flumazenil contraindications carefully

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