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Benzodiazepine Toxicity Nursing Guide

Content reviewed by Ann Dietrich, MD, FAAP, FACEP.

Benzodiazepine Toxicity Etiology and epidemiology 

  • Benzodiazepines (BZDs) are a class of medications that enhance the inhibitory action of neurotransmission at post-synaptic GABA (gamma-aminobutyric acid) receptor sites. They’re used as anxiolytics, muscle relaxants, anticonvulsants, and sleep aids. BZDs are metabolized in the liver and are commonly abused as street drugs. In 2019, benzodiazepines were implicated in 16% of opioid overdose deaths (CDC, n.d.). 
  • Flumazenil (Romazicon®) is the antidote for benzodiazepine toxicity, but it must be used cautiously as it can precipitate seizures and withdrawal symptoms,  in chronic users (Soyka, 2017). BZD withdrawal is typically treated with a long-acting BZD, such as clonazepam (Klonopin®) (Ait-Daoud et al., 2018). 

Complications of benzodiazepine toxicity 

  • Respiratory depression: The most common and potentially fatal complication. 
  • Accidental injury: Due to sedation and impaired motor function. 
  • Rhabdomyolysis: Rare when BZDs are used alone but can occur. 
  • Aspiration pneumonia: Due to reduced consciousness and compromised airway protection. 

Risk factors 

  • Overdose potential: Especially when combined with other central nervous system depressants. 
  • Addiction: High potential for dependency and misuse. 

Benzodiazepine Toxicity Diagnosis 

Diagnostic testing 

  • Urine drug screen: To confirm the presence of benzodiazepines and other substances. 
  • Serum electrolytes, glucose, BUN, creatinine clearance: To assess the metabolic impact of the overdose. 
  • ABG (arterial blood gas): In cases of respiratory depression to assess oxygenation and acid-base balance. 
  • ECG/EKG: Required if other coingestants (e.g., tricyclic antidepressants) are suspected, as these can affect cardiac rhythm. 
  • Chest X-ray: If aspiration pneumonia is suspected. 
  • HCG: To rule out pregnancy if suspected. 

Management 

Immediate care 

  • ABCs (airway, breathing, circulation): Prioritize maintaining airway patency, adequate ventilation, and circulation. 
  • Endotracheal intubation: May be necessary if there is severe respiratory depression. 
  • Supplemental oxygen: Administer as needed to maintain oxygen saturation. 
  • Cardiac monitoring: Continuous ECG/EKG and pulse oximetry monitoring. 
  • NPO (Nothing by mouth): Until the patient is fully awake, alert, and able to protect their airway. 
  • Observation: Monitor in the emergency department or admit to the hospital if other substances were ingested or if there are severe symptoms. 
  • Flumazenil: Administer only in cases of iatrogenic BZD overdose in BZD-naïve individuals. It is not recommended for chronic BZD users due to the risk of precipitating withdrawal seizures. 

Benzodiazepine Toxicity Nursing Care Plan

Nursing considerations 

Assessment 

  • History: 
    • Determine the dose, amount, and time of the last BZD taken. 
    • Assess whether the overdose was accidental or intentional. 
    • Check for symptoms such as nausea or vomiting. 
  • Physical examination: 
    • Assess for a decreased level of consciousness. 
    • Monitor for changes in mental status, such as hostility, excitement, hallucinations, or confusion. 
    • Observe for lateral nystagmus, slurred speech, low muscle tone, seizure activity, dizziness, blurred vision, and signs of respiratory depression or hypotension. 

Nursing diagnoses 

  • Ineffective breathing pattern: Associated with central nervous system depression from benzodiazepine toxicity. 
  • Inability to sustain spontaneous respiration: Due to severe respiratory depression. 
  • Poisoning: Related to benzodiazepine overdose. 
  • Knowledge deficit: Related to the safe use and potential risks of benzodiazepine use. 

Interventions 

  • Airway management: Provide supportive measures to maintain airway patency and adequate breathing. 
  • Fluid administration: Administer IV fluids as ordered to maintain hydration and support blood pressure. 
  • ECG/EKG monitoring: Continuously monitor cardiac rhythm. 
  • Psychosocial support: Offer emotional support to the patient and their family. 
  • Monitoring: 
    • Regularly assess the level of consciousness and respiratory status. 
    • Monitor vital signs and ABCs (airway, breathing, and circulation). 
    • Observe for any signs of psychological distress or suicidal ideation. 

Expected outcomes 

  • Neurological and respiratory recovery: The patient will return to baseline neurological and respiratory functioning. 
  • Safe use of benzodiazepines: The patient and caregivers will understand the importance of medication safety and the risks of overdose. 
  • Appropriate follow-up: The patient will follow up with healthcare providers as recommended, particularly in cases of intentional overdose. 

Individual/caregiver education 

  • Safe storage of medications: Ensure that benzodiazepines are stored securely to prevent accidental ingestion, especially by children. 
  • Safe use of benzodiazepines: Educate on taking medications exactly as prescribed and the dangers of mixing BZDs with other substances, especially alcohol. 
  • Recognizing toxicity: Teach the signs of benzodiazepine toxicity, including excessive sedation, confusion, and respiratory depression. 
  • Follow-up care: Encourage follow-up with healthcare providers, especially mental health professionals, if the overdose was intentional. 
  • Supervision: Advise that medications should be administered by a responsible adult in individuals at risk for overdose. 

ICD-10 code for benzodiazepine toxicity 

  • T42.4X1A — Poisoning by benzodiazepines, accidental (unintentional), initial encounter 

FAQs

Additional Information

Content Release Date 

4/1/2022

Content Expiration

8/31/2027

References

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