Moffitt AM Report 4/26/17: Benzodiazepine Overdose

Good afternoon!

Thank you Jin for presenting the case of an elderly woman with NSTEMI, who had an acute onset of altered mental status in the setting of accidental benzodiazepine overdose.

SamMy (Sam & Myung)



  • Respiratory compromise is UNCOMMON  with isolated oral ingestion of benzodiazepines, but may be seen in the setting of coingestion (eg ethanol)
  • Standard urine toxicology screens do NOT detect all BZD agents. This is because most common BZD urine test only identifies metabolites of 1,4-benzodiazepine (such as oxazepam). Hence, this test may not detect clonazepam, lorazepam, midazolam, or alprazolam.

See this diagram from Jin on benzo metabolism, which explains why not all benzodiazepines are detected on urine tox screens!


  • Flumazenil is a nonspecific competitive antagonist of the BZD receptor, and is an antidote for BZD overdose (but clinical utility is controversial)
  • Avoid flumazenil in patients with tolerance to benzodiazepines (chronic users/abusers), since it can precipitate withdrawal seizures

More on Flumazenil

  • Nonspecific competitive antagonist of the BZD receptor
  • Use of flumazenil is highly controversial – it can precipitate withdrawal seizures in patients who have tolerance to BZD through chronic use. Hence is preferentially used in cases of accidental overdose in non-dependent patients
  • Does NOT reverse respiratory depression caused by BZD overdose
  • Dose: 0.2 mg IV over 30 seconds. Repeat doses to a maximum dose of 1 mg
  • Peak effect of a single dose administration is 6-10 min
  • Duration is short (0.7 – 1.3 hours). Hence, duration of effect of a long-acting BZD can exceed that of flumazenil

Evernote Link:





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