Sedative Hypnotics

Barbituates

Enhance activity of GABA, in higher doses, allow Cl influx even if GABA not bound

The picture of a barb overdose is just like benzos but with a much greater chance of resp depression. Coma with normal vitals except decreased RR.

People were dying until Scandanavian method, intubate them and then let them wake up.

To hasten elimination, consider alkalinization of urine or charcoal hemoperfusion, but very rarely are these indicated due to the benign course so long as supportive care is available

Withdrawl-seizures, autonomic dysfunction. Give 30 mg of Phenobarb for each 100 mg of short acting, in divided doses then taper.

Can sometimes see barb blisters-blisters on non-dependant portions of body

Suicide drug of choice overseas, take overdose of barbs and then tape a garbage bag over your head to really do the job

Benzodiazepines

Mild hypothermia, mild hypotension, mild reduction in HR, CNS depression, mild resp depression

Use Flumazenil only after conscious sedation in patients well screened.

.2 mg over 30 seconds

flumaz seizure risk may be exaggerated ann emerg med Volume 51, Issue 4, Page 473 (April 2008)

but maybe not…

Brierley J. Danger of flumazenil use in pediatric status epilepticus. Pediatr Emerg Care. 2006 Mar;22(3):168-9. PubMed PMID: 16628099.

Spivey WH. Flumazenil and seizures: analysis of 43 cases. Clin Ther. 1992 Mar-Apr;14(2):292-305. Review. PubMed PMID: 1611650.

and

(PMID: 22766408)

GHB

Gamma-Hydroxybutyrate (GHB, Grievious Bodily Harm)

Also precursors gamma-butyrolactone (GBL) and butanediol (BD)

Potent CNS depressant

Increases dopamine concentrations in cortex. binds to GABA, and specific binding to a receptor which causes CNS depressant effect

Patients may cycle between periods of apnea and agitation with hyperventilation

Non-symptomatic bradycardia is common

Amnesia and Hypotonia

Somnolence, euphoria, dizziness and hallucinations (by acting as gaba in substantia nigra)

Doesnt cause seizure activity, but can cause clonic movements

Can cause symptomatic bradycardia. High doses can result in resp depression and coma

GBL is a precursor that gets metabolized to GHB and is much more potent

If resistant to high dose benzos, can use small doses of pentobarbital (1-2 mg/kg q 30-60 minutes) (Ann Emerg Med 38:6)

give benzos for withdrawl from GHB

best review (Acad Emerg Med 2002;9(7):730)

5-MEO-DMT

hallucinogen available over the net

hypotonicity leading to seizures

Non-Barb, Non-Benzo

Ambien

Partially reversible c flumazenil

Chloral Hydrate

used as knockout drops, first popularized by bar owner Mickey Finn Potentiates ETOH effects by preventing breakdown

Can have corrosive GI effects

Odor of Pears

Can use B-Blockers if Ventricular dysrhythmias

Still used as a sedative for peds and elderly as less paradoxical excitement effects

Ethchlorvynol (Placidyl)

pulmonary edema (NCPE), can cause bullae as well, decontam, supportive care

Glutethimide

cyclic coma

Meprobamate

Soma, give ac

Methaqualone

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