THE POISONED PATIENT WITH ALTERED CONSCIOUSNESS - CONTROVERSIES IN THE USE OF A COMA COCKTAIL

Objective.-In the assessment and management of the potentially poisone d patient with altered consciousness, the most consequential and contr oversial interventions occur during the first 5 minutes of care. In th is review article, the risks and benefits of standard diagnostic and t herapeutic interventions are presented to guide clinicians through thi s critical period of decision making. Data Sources.-Data for discussio n were obtained from a search of English-language publications referen ced on MEDLINE for the years 1966 to 1994. Older literature was includ ed when pertinent. Search terms included poisoning, overdose, toxicity , naloxone, glucose, thiamine, and flumazenil. Study Selection.-Only l arge trials were used for determinations of diagnostic utility and eff icacy. Small trials, case series, and case reports were reviewed exten sively for adverse effects. Data Extraction and Synthesis.-Trials were reviewed for overall methodology, inclusion and exclusion criteria, s ources of bias, and outcome. Conclusion.-Analysis favors empirical adm inistration of hypertonic dextrose and thiamine hydrochloride to patie nts with altered consciousness. Although rapid reagent test strips can be used to guide this therapy, they are not infallible, and they fail to recognize clinical hypoglycemia that may occur without numerical h ypoglycemia. Administration of naloxone hydrochloride should be reserv ed for patients with signs and symptoms of opioid intoxication. Flumaz enil is best left for reversal of therapeutic conscious sedation and r are select cases of benzodiazepine overdose.