{"id":2891,"date":"2021-07-08T10:21:50","date_gmt":"2021-07-08T10:21:50","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-newsletters\/?p=2891"},"modified":"2025-04-11T04:03:17","modified_gmt":"2025-04-11T04:03:17","slug":"an-interesting-case-of-drug-overdosage","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-july-2021\/an-interesting-case-of-drug-overdosage\/","title":{"rendered":"An Interesting Case of Drug Overdosage"},"content":{"rendered":"<p class=\"caps\">[vc_row][vc_column][vc_column_text]<\/p>\n<h2><strong>Case presentation<\/strong><\/h2>\n<p><strong>\u00a0<\/strong>A 65-year-old lady was brought with sudden onset of drowsiness associated with breathing difficulty and increased frequency of urination since the morning of 3\\6\\2021. The attendant saw her normal at 11:30pm on 2\\6\\2021<\/p>\n<ul>\n<li>No H\/o fever, cough, vomiting, loose stools, trauma, head injury, chest pain, palpitation, sweating, seizure,<\/li>\n<li>H\/o covishield vaccination 2<sup>nd<\/sup> dose completed on May 2021<\/li>\n<li><strong>Past medical history <\/strong>: The patient is a known hypertension and dyslipidemia case<\/li>\n<\/ul>\n<h2><strong>\u00a0<\/strong><strong>On examination:<\/strong><\/h2>\n<ul>\n<li>The patient was drowsy, arousable, febrile, dehydrated ++. Tachypneic<\/li>\n<li>A \u2013 Threatened, noisy breathing,<\/li>\n<li>B \u2013 B\/L AE + B\/L basal crepts + , conducted sounds +, RR \u2013 32, Spo2 \u2013 88% RA<\/li>\n<li>C \u2013 B\/L PPWF + , CVS \u2013 S1S2 + ,HR \u2013 92, BP \u2013 100\/60,<\/li>\n<li>D \u2013 E3V2M4 ,B\/L pupils pin point (1mm), moving all 4 limbs<\/li>\n<li>E \u2013 Temp \u2013 100.6\u2019F<\/li>\n<\/ul>\n<p><strong>Bedside investigation done<\/strong><strong>\u00a0<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-2892 size-full\" src=\"https:\/\/www.kauveryhospital.com\/ima-newsletters\/wp-content\/uploads\/2021\/07\/New-Project23.jpg\" alt=\"\" width=\"452\" height=\"182\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project23.jpg 452w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project23-300x121.jpg 300w\" sizes=\"auto, (max-width: 452px) 100vw, 452px\" \/><\/p>\n<ul>\n<li>Sinus rhythm<\/li>\n<li>Rate \u2013 100 bts\/min<\/li>\n<li>Normal axis<\/li>\n<li>No acute st-t changes<\/li>\n<\/ul>\n<p><strong>Echo<\/strong><\/p>\n<ul>\n<li>Sclerotic aortic valve<\/li>\n<li>Mild AR\/ trivial MR<\/li>\n<li>Mild TR \/PAH (PASH \u2013 48mmhg)<\/li>\n<li>Normal RV function<\/li>\n<li>No RWMA<\/li>\n<li>Good LV systolic function (EF \u2013 60%)<\/li>\n<li>Reduced diastolic compliance<\/li>\n<\/ul>\n<p><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-2906\" src=\"https:\/\/www.kauveryhospital.com\/ima-newsletters\/wp-content\/uploads\/2021\/07\/New-Project32.jpg\" alt=\"\" width=\"450\" height=\"218\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project32.jpg 666w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project32-300x145.jpg 300w\" sizes=\"auto, (max-width: 450px) 100vw, 450px\" \/><\/strong><\/p>\n<p><strong>Regular medication<\/strong><strong>\u00a0<\/strong><\/p>\n<ul>\n<li>\u2013 Zolfresh 10mg HS<\/li>\n<li>\u2013 Cilacar 10mg BD<\/li>\n<li>\u2013 Metosartan 50mg OD<\/li>\n<li>\u2013 Nexito plus OD<\/li>\n<li>\u2013 Rozavel 10mg HS<\/li>\n<\/ul>\n<p><strong>Provisional diagnosis<\/strong><strong>\u00a0<\/strong><\/p>\n<ul>\n<li>Probably sespsis with septic shock -&gt; lung source? Pneumonia vs seizure disorder<\/li>\n<li>AKI<\/li>\n<\/ul>\n<h2><strong>Further investigations revealed the following:<\/strong><strong>\u00a0<\/strong><\/h2>\n<ul>\n<li>CBC \u2013 Leucocytosis with neutrophilia and lymphophenia (TC \u2013 11800, N79.5, L120)<\/li>\n<li>Low normal platelets at 1.68 lakhs<\/li>\n<li>Normal RFT and LFT<\/li>\n<li>Mildly elevated CRP \u2013 6.02<\/li>\n<li>Elevated D-Dimer \u2013 1800<\/li>\n<li>Normal procalcitonin \u2013 0.78<\/li>\n<li>Urine routine \u2013 WNL<\/li>\n<li>Urine toxicology screen +ve (positive) for Benzodiazepine<\/li>\n<li>RT PCR Covid swab test \u2013 Negative<\/li>\n<\/ul>\n<p><strong>CT brain<\/strong><strong>\u00a0<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-2893 size-full\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project27.jpg\" alt=\"\" width=\"208\" height=\"244\" \/><\/p>\n<ul>\n<li>Chronic lacunar infarct in the right thalamus<\/li>\n<li>Small vessel ischemic changes<\/li>\n<\/ul>\n<p><strong>CT abdomen<\/strong><strong>\u00a0<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-2894\" src=\"https:\/\/www.kauveryhospital.com\/ima-newsletters\/wp-content\/uploads\/2021\/07\/New-Project26-232x300.jpg\" alt=\"\" width=\"232\" height=\"300\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project26-232x300.jpg 232w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project26.jpg 252w\" sizes=\"auto, (max-width: 232px) 100vw, 232px\" \/><\/p>\n<ul>\n<li>Fatty liver<\/li>\n<li>B\/L small-sized kidneys with cortical scars<\/li>\n<li>Right adnexal cyst<\/li>\n<\/ul>\n<p><strong>CT chest<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-2895\" src=\"https:\/\/www.kauveryhospital.com\/ima-newsletters\/wp-content\/uploads\/2021\/07\/New-Project28-230x300.jpg\" alt=\"\" width=\"230\" height=\"300\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project28-230x300.jpg 230w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project28.jpg 242w\" sizes=\"auto, (max-width: 230px) 100vw, 230px\" \/><\/p>\n<ul>\n<li>Mild cardimegaly with pericardial thickening and bilateral mild pleural effusion<\/li>\n<li>Subtle subpleural ground glass attenuation with interlobular septal thickening in left upper lobe anterior segment<\/li>\n<li>Areas of consolidation with air bronchogram in the right upper and middle lobe<\/li>\n<li>Consolidation with branchogram and surrounding ground glass opacities in the right lower lobe superior and medical segment in the central perihilar location \u2013 R\/O neoplastic ethology<\/li>\n<\/ul>\n<h2><strong>Suspicion<\/strong><\/h2>\n<p><strong>\u00a0<\/strong>In suspicion of exact reason for <strong>drowsiness, hypotension, desaturation, <\/strong>which was unexplained by lab investigations and clinical finding, attenders were probed again deeply in regard to drug history.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2896 alignright\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project29.jpg\" alt=\"\" width=\"164\" height=\"136\" \/><\/p>\n<ul>\n<li>We had a suspicion of drug overdose -&gt; advised attendants to go back and see tablet box<\/li>\n<li>Patient apparently was on tab. \u2013 ZOLFRESH 10MG OD<\/li>\n<li>The attendants later went through the patient\u2019s medicine box to see all tablets are missing from the 2 strips of Zolfresh 10 mg, each containing 12 tabs which were brought just 2 days ago<\/li>\n<\/ul>\n<h2><strong>Management<\/strong><\/h2>\n<ul>\n<li>Inj \u2013 Paracetamol 1gm iv stat -&gt; in v\/o fever<\/li>\n<li>Inj \u2013 Pan 40mg iv stat<\/li>\n<li>Inj \u2013 Emeset 4mg iv stat<\/li>\n<li>Ivf \u2013 ns 500ml bonus -&gt; in v\/o bp 100\/60 (in v\/o hypotension) repeat bp 110\/60<\/li>\n<li>Inj \u2013 magnex forte 3gm iv stat<\/li>\n<li>Ryle\u2019s tube insertion -&gt; with continuous aspiration<\/li>\n<li>Foley\u2019s 16 size catheterization done -&gt; clear urine drained 150ml<\/li>\n<li>All supportive measures were taken, and the patient was admitted to ICU for further neuro-observation of vitals.<\/li>\n<li>This patient recovered with supportive measures and symptomatic treatment and was discharged after 5 days of hospital stay and obtaining psychiatric counseling<\/li>\n<\/ul>\n<h2><strong>Discussion<\/strong><\/h2>\n<p><strong>\u00a0<\/strong><strong>Clinical features of benzodiazepines overdosage<\/strong><\/p>\n<ul>\n<li>Rapid with most developing symptoms within 4 hours<\/li>\n<li>Patient initially present with mild-to-moderate impairment of CNS function.<\/li>\n<li>Severe overdose can lead to prolonged deep coma, apnea, respiratory depression, hypothermia, Brady cardia, cardiac arrest, pulmonary aspiration,<\/li>\n<li>Drowsiness<\/li>\n<li>Dizziness<\/li>\n<li>Ataxia<\/li>\n<li>Dysarthria<\/li>\n<li>Confusion<\/li>\n<li>Hypotension<\/li>\n<\/ul>\n<h2><strong>Toxicity<\/strong><\/h2>\n<ul>\n<li>Benzodiazepines have a wide therapeutic index and taken alone in overdose rarely cause severe complications or fatalities<\/li>\n<li>Taken in overdose in combinations with alcohol, opioids, tricycles antidepressants are particularly dangerous<\/li>\n<li>Elderly and those chronic illness are much more vulnerable to lethal overdose with benzodiazepines<\/li>\n<\/ul>\n<h2><strong>Benzodiazepines antogonist <\/strong><strong>&#8211;&gt;<\/strong><strong> flumazenil<\/strong><\/h2>\n<p><strong>\u00a0<\/strong><strong>Indications<\/strong><\/p>\n<ul>\n<li>Reversal of benzodiazepines sedation<\/li>\n<li>Benzodiazepines toxicity<\/li>\n<\/ul>\n<p><strong>Contraindications<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2899 alignright\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/07\/New-Project31.jpg\" alt=\"\" width=\"194\" height=\"228\" \/><\/p>\n<ul>\n<li>Known seizure disorder<\/li>\n<li>Overdose of unknown agents<\/li>\n<li>Suspected or known physical dependence on benzodiazepines<\/li>\n<li>Suspected cyclic antidepressants overdose<\/li>\n<li>Suspected increased intracranial pressure<\/li>\n<li>Co \u2013 ingestion of seizure inducing agents<\/li>\n<li>Flumazenil is a benzodiazepines receptor antagonist that can be used as an antidote for benzodiazepines overdose<\/li>\n<li><strong>Specific antagonist for benzodiapines -&gt; flumazenil at 0.2mg \/ min <\/strong>maximum dose of 3g\/h, but it may precipitate seizures and intracranial pressure.<\/li>\n<li>Flumazenil should be avoided if the patient is dependent on benzodiazepines or takes tricyclic antidepressants as it can precipitate withdrawal syndrome and cardiac arrest<\/li>\n<li>Oral bioavailability is very less -&gt;not used orally<\/li>\n<li>I\/V injection action starts within seconds and lasts for 1-2hrs<\/li>\n<li>It also has no role in the management of unknown overdose<\/li>\n<li><strong>In addition, if full airway protection has been achieved, a good outcome is expected and therefore flumazenil is unlikely to be required (GCS)<\/strong><\/li>\n<li>It is very effective at reversing the CNS depression associated with benzodiazepines but less effective in respiratory depression<\/li>\n<li>It has short half life, and duration of action of flumazenil is less than 1 hour<\/li>\n<\/ul>\n<h2><strong>Take-home points<\/strong><\/h2>\n<ul>\n<li>An incomplete history which does not corroborate all the clinical signs and symptoms should push us to go back and retake the history.<\/li>\n<li>If clinical situations like mentioned above should arise, we should suspect drug overdose.<\/li>\n<\/ul>\n<p><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-2797 size-thumbnail\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2021\/06\/noor-150x150.jpg\" alt=\"\" width=\"150\" height=\"150\" \/>Dr. Noor Akbar<\/strong><br \/>\nMRCEM Resident \u2013 Dept. of Emergency Medicine<br \/>\nKauvery Hospital, Chennai[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_column_text] Case presentation \u00a0A 65-year-old lady was brought with sudden onset of drowsiness associated with breathing difficulty and increased frequency of urination since the morning of 3\\6\\2021. The attendant saw<\/p>\n","protected":false},"author":2,"featured_media":2901,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[31],"tags":[],"class_list":["post-2891","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-july-2021"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>An Interesting Case of Drug Overdosage<\/title>\n<meta name=\"description\" content=\"Case presentation : A 65-year-old lady was brought with sudden onset of drowsiness associated with breathing difficulty and increased frequency of urination since the morning of 362021.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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