A 22-year-old woman is brought to the emergency department with drowsiness after ingesting an unknown quantity of her mother's alprazolam. She is rousable with a Glasgow Coma Scale of 13 and respiratory rate is 16/min. The most appropriate next step is:

• A Intravenous flumazenil immediately to reverse coma
• B Intravenous naloxone followed by activated charcoal
• C Supportive care with observation, reserving flumazenil for severe respiratory depression ✓
• D Intubation and mechanical ventilation regardless of examination findings

Explanation

Uncomplicated benzodiazepine overdose is managed supportively because it rarely causes life-threatening respiratory depression when taken alone. Flumazenil reverses sedation but precipitates acute withdrawal and seizures in chronically dependent patients and can unmask co-ingested proconvulsant drugs such as TCAs, so it is reserved for selected cases of severe respiratory depression. Naloxone antagonises opioids, not benzodiazepines.

Reference: Katzung's Basic and Clinical Pharmacology, 15th ed.

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Written and medically reviewed by the StethoPrep medical team.