Alcoholic Who Has Taken Tamazepam OD

[old pal grover]

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How do you stop and alcoholic who has taken a tamazepam od going into withdrawal? Do you wait for them to recover from the OD and then write up some diazepam as usual?

Thanks

 

[Polish Farmer]

I'm not sure I understand your question. If your pt. has OD'd on benzos you give them flumazenil, but if you have a pt. hospitalized who is starting to WD (from etoh or benzos) the treatment is: CIWA with your choice of benzo, my personal favorite is clorazepate. If they are going to stay in the hospital and have a high potential for WD then starting scheduled benzos is acceptable, personally I have found it is impossible to predict who will WD and when they will WD, unless you have personally taken care of them before or have a history of severe WD. So I usually start prn benzos with CIWA and go to scheduled ones if things are looking bad. You need to be vigilant because before long they may become delerious and you will have to tube them.

One of three things usually happens:
1) they get tubed and spend some time in the unit
2) they have a "light" WD that you can manage
3) they start to WD, but go AMA before they lose their capacity - then go home and drink

 

[old pal grover]

Thanks for the reply 🙂

What if they are an alcoholic who has overdosed on tamazepam?
I'm wondering if it is safe to write-up diazepam if they start to show signs of alcohol WD in this situation?

 

[werd]

you can't be withdrawing and overdosed from something at the same time. if someone has recently overdosed but is now withdrawing, then they're no longer overdosed.... and you treat the withdrawl like normal.

 

[Rendar5]

I'm not sure I understand your question. If your pt. has OD'd on benzos you give them flumazenil, but if you have a pt. hospitalized who is starting to WD (from etoh or benzos) the treatment is: CIWA with your choice of benzo, my personal favorite is clorazepate. If they are going to stay in the hospital and have a high potential for WD then starting scheduled benzos is acceptable, personally I have found it is impossible to predict who will WD and when they will WD, unless you have personally taken care of them before or have a history of severe WD. So I usually start prn benzos with CIWA and go to scheduled ones if things are looking bad. You need to be vigilant because before long they may become delerious and you will have to tube them.

One of three things usually happens:
1) they get tubed and spend some time in the unit
2) they have a "light" WD that you can manage
3) they start to WD, but go AMA before they lose their capacity - then go home and drink

Exactly as above poster said, but you should almost never ever use flumazenil, especially in above patient. It would put him into hyperacute benzo withdrawal, complete with seizures and all other deleterious effects. The only time to use flumazenil is in someone who you know 100% fact does not use benzo's on any sort of chronic basis (which is rare unless you're talking about anaesthesiology practice or something), not to mention that in an hour when the flumazenil wears off, you're back in the exact same boat you were to begin with.

The key in your situation is supportive treatment, including intubation as needed. Leave the benzo's on board since they're already treating his alcohol withdrawal. The same as if you're dealing with an alcoholic who's placed on any drug or OD's on any drug that treats withdrawal (such as propofol if you intubated someone). CIWA protocols vary from hospital to hospital, but regardless you have the nurses watch for withdrawal symptoms which will appear as the benzo's wear off, and you yourself keep an eye since as the benzo's wear off you're likely to need to titrate up the dose of your own benzo's you give for the withdrawal.

 

[jdh71]

Exactly as above poster said, but you should almost never ever use flumazenil, especially in above patient. It would put him into hyperacute benzo withdrawal, complete with seizures and all other deleterious effects. The only time to use flumazenil is in someone who you know 100% fact does not use benzo's on any sort of chronic basis (which is rare unless you're talking about anaesthesiology practice or something), not to mention that in an hour when the flumazenil wears off, you're back in the exact same boat you were to begin with.

The key in your situation is supportive treatment, including intubation as needed. Leave the benzo's on board since they're already treating his alcohol withdrawal. The same as if you're dealing with an alcoholic who's placed on any drug or OD's on any drug that treats withdrawal (such as propofol if you intubated someone). CIWA protocols vary from hospital to hospital, but regardless you have the nurses watch for withdrawal symptoms which will appear as the benzo's wear off, and you yourself keep an eye since as the benzo's wear off you're likely to need to titrate up the dose of your own benzo's you give for the withdrawal.

👍

flumazenil is a big no-no, sounds great in theory . . . just tube the patient and wait it out

you use much dexmedetomidine for EtOH withdrawal? I love it

 

[Knicks]

If Flumazenil is a "big no-no", why does First Aid beat it into our heads? Wouldn't it be better if they just taught us everything clinically done, not this "never-gonna-be-used-in-actual-practice theory".

 

[SouthernSurgeon]

If Flumazenil is a "big no-no", why does First Aid beat it into our heads? Wouldn't it be better if they just taught us everything clinically done, not this "never-gonna-be-used-in-actual-practice theory".

Get used to it. That's how it happens for about half the stuff in first aid. You will also realize that Step 1 deliberately tests you on out of date drugs you will never see in practice (because they like to test on the CYP interactions), etc.

 

[jdh71]

If Flumazenil is a "big no-no", why does First Aid beat it into our heads? Wouldn't it be better if they just taught us everything clinically done, not this "never-gonna-be-used-in-actual-practice theory".

I don't know why they do that. I suppose because there is a disconnect between the basic and clinical sciences and it takes years to communicate. Plus I think the basic sciences are just trying to get you used to "thinking around the corners" of how it all connects and can be helpful. I remember being more than a little horrified when I realized how little of all of the pathology I had learned I was ever actually going to see and how much I was going to see once in a career, if I was lucky. And chloramphenicol . . . come on guys . . . I don't even think it's been manufactured, let a long used in this country for like 30 years.

Welcome to the guild I guess.