Background: Benzodiazepines (BZD) are sedative-hypnotic agents. BZD act as positive allosteric modulators on the gamma amino butyric acid (GABA)-A receptor. GABA is inhibitory in nature and thus reduces the excitability of neurons. Diazepam, a long-acting BZD, produces the active metabolites who increase the duration of the drug action. Slow hepatic extraction and a large volume of distribution (V d) result in a long elimination half-life for diazepam (30 h).

Case presentation:  A comatose, apneic patient was presented in the emergency department, patient’s pupils were myopic and symmetrical, vital signs: TA 160/100, HR 45, GCS= 5. The patient was intubated, was administered atropine in two doses: 0.5mg and a second dose 0.5 mg, he was transferred to ICU, and set on a mechanical ventilation on BIPAP Fi02=50%, PEEP=5. His vital parameters were TA 160/100, HR 100, SpO2 98%. He was sedated with Fentanyl 30mg/Midazolam 100mg/3 ml/h, and because of the bradycardia (up to 40 beats/min) Atropin 0.5 mg was administered several times. The laboratory report showed elevated Leu 43.8 and Glu 28.9. The patient was given Actrapid 16IE, 2000 ml fluids, and the acid-base status was assessed.  The acid-base status showed pH 7.239, pCO2 3.92, p02 30.96, HCO3 12.7, BEecf -14.9, and consequently the patient was given NaHCO3 40ml. After 3 hours, the acid-base status was re-examined, reading: pH 7.296; pCO24.72; p02 32.62, HCO3 17.5; BEecf -9.2. The CT scans showed no abnormal findings. The toxicological measurements in the patient’s serum showed positive findings on benzodiazepines, 856ng/ml or 4 times higher than normal values. The sedation was discontinued, and after 5 hours, the patient was awake and contactable, extubated and supported by oxygen mask. The blood parameters were improving with a tendency of drop of Leu 19.8, stabilized glucose levels to 4.6. The acid-base status was improved, pH 7.33. After 3 days hospitalization in the ICU, the patient was transferred in the toxicology department.  
Discussion:  As with any overdose, the first step is to assess the patient's airway, breathing, and circulation and to address these rapidly as needed. The cornerstone of treatment in benzodiazepine overdoses is good supportive care and monitoring. Patients may be discharged if they remain asymptomatic at least 6 hours post ingestion. In acute drug poisoning, a high index of clinical suspicion and an early and prompt intensive medical therapy could improve the patient outcome.


03 / Patient intoxicated with benzodiazepines, case report.