title: Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department?
abstract: Patients in coma with suspected drug poisoning are commonly encountered in the emergency department. Benzodiazepines are one of the most commonly used drugs in self-poisoning. Flumazenil, a benzodiazepine antagonist has been suggested as a diagnostic and treatment tool in suspected poisoning of unclear cause, but caution is required due to potential side effects. No systemic review of this literature has been done on this topic.
  
  
  OBJECTIVE
  The aim of this study is to examine if flumazenil should be used in patients with coma from suspected drug poisoning.
  
  
  METHODS
  Randomised controlled trials were identified from the Cochrane Library, Pubmed and EMBASE. Bibliographies from included studies, known reviews and texts were searched. Content experts were contacted.
  
  
  METHODS
  Randomised controlled trials were eligible for inclusion. Studies were included if patients who presented with altered mental state from suspected drug poisoning were treated with intravenous flumazenil as compared to placebo.
  
  
  METHODS
  Data were extracted and methodological quality was assessed independently by two reviewers.
  
  
  RESULTS
  Seven randomised controlled trials were included. A total of 466 patients were involved. Flumazenil was found to reverse coma from suspected drug poisoning with a relative benefit of 4.45 (95% CI 2.65, 7.45). In terms of major side effects, there was no statistical difference between flumazenil and placebo (RR 2.86, 95% CI 0.12-69.32). However, in terms of minor side effects, flumazenil was associated with a higher incidence of anxiety (RR 2.84, 95% CI 1.28-6.30) and other side effects (RR 3.73, 95% CI 2.078-6.73). There was no difference in the incidence of vomiting (RR 4.28, 95% CI 0.95-19.35).
  
  
  CONCLUSIONS
  Current evidence shows that flumazenil may be effective in the reversal of coma in patients presenting to the emergency department with coma from suspected drug poisoning.
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. adelinengosy@hotmail.com
authors.forename: Adeline Su-Yin
authors.initials: AS
authors.lastname: Ngo
authors.forename: Charles Rabind
authors.initials: CR
authors.lastname: Anthony
authors.forename: Miny
authors.initials: M
authors.lastname: Samuel
authors.forename: Evelyn
authors.initials: E
authors.lastname: Wong
authors.forename: R
authors.initials: R
authors.lastname: Ponampalam
mesh_terms: D000931:Antidotes / Q000008:administration & dosage*; D001569:Benzodiazepines / Q000037:antagonists & inhibitors* / Q000506:poisoning*; D003128:Coma / Q000139:chemically induced*; D005442:Flumazenil / Q000008:administration & dosage*; D015600:Glasgow Coma Scale; D006801:Humans; D016032:Randomized Controlled Trials as Topic
chemical_list: D000931:Antidotes; D001569:Benzodiazepines; D005442:Flumazenil