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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}} {{Alison}}
|QuestionAuthor={{YD}} {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pharmacology
|MainCategory=Pharmacology
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|MainCategory=Pharmacology
|MainCategory=Pharmacology
|SubCategory=Neurology
|SubCategory=Neurology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
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|MainCategory=Pharmacology
|MainCategory=Pharmacology
|SubCategory=Neurology
|SubCategory=Neurology
|Prompt=A 28-year-old male is brought to the emergency room for excessive somnolence, impaired balance, and impaired motor function.  Suspecting a benzodiazepine overdose, flumazenil is administered at the appropriate dose and infusion rate.  A few seconds following the administration of flumazenil, the patient’s wife arrives and explains that her husband attempted suicide by excessively ingesting a benzodiazepine and a tricyclic antidepressant.  Which of the following symptoms will the patient most likely experience following the administration of flumazenil?
|Prompt=A 28-year-old man is brought to the emergency department for excessive somnolence and impaired motor function.  Suspecting a benzodiazepine overdose, flumazenil is immediately administered.  A few seconds following the administration of flumazenil, the patient’s wife arrives to the emergency department and confirms that her husband likely attempted suicide by ingesting a handful of her anxiety pills which include lorazepam and fluoxetine.  Which of the following symptoms will the patient most likely experience following the administration of flumazenil?
|Explanation=[[Flumazenil]] should be used carefully in patients who have a history of [[seizures]], such as [[epilepsy]], or when there is suspicion of a mixed [[overdose]]. The use of [[flumazenil]], when a [[benzodiazepine]] ([[BZD]]) is co-ingested with [[tricyclic antidepressants]] ([[TCA]], often manifests with seizures, a side effect of [[tricyclic antidepressants]].  The seizure is not believed to be a side effect of [[flumazenil]] itself, rather one of [[tricyclic antidepressants]] that occurs when the effect of a [[benzodiazepine]] is reversed.
|Explanation=[[Flumazenil]] is a  GABA<sub>A</sub> receptor antagonist used primarily for the treatment of benzodiazepine overdoses. [[Flumazenil]] should be used carefully in patients who have a history of [[seizures]], such as [[epilepsy]], or when there is suspicion of a mixed [[overdose]]. The use of [[flumazenil]], when a [[benzodiazepine]] ([[BZD]]) is co-ingested with [[tricyclic antidepressants]] ([[TCA]], often manifests with seizures, a side effect of [[tricyclic antidepressants]].  The seizure is not believed to be a side effect of [[flumazenil]] itself, rather one of [[tricyclic antidepressants]] that occurs when the effect of a [[benzodiazepine]] is reversed.
 
As a result a risk-to-benefit ratio in patients must be considered when administering [[flumazenil]].
 
|EducationalObjectives= The use of [[flumazenil]], when a [[benzodiazepine]] ([[BZD]]) is co-ingested with [[tricyclic antidepressants]] ([[TCA]], often manifests with seizures, a side effect of [[tricyclic antidepressants]].  The seizure is not believed to be a side effect of [[flumazenil]] itself, rather one of [[tricyclic antidepressants]] that occurs when the effect of a [[benzodiazepine]] is reversed.
|References= Spivey WH. Flumazenil and seizures: analysis of 43 cases. Clin Ther. 1992; 14(2):292-305.
 
Haverkos GP, DiSalvo RP, Imhoff TE. Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother. 1994;28(12):1347-9.
 
|AnswerA=Seizure
|AnswerA=Seizure
|AnswerAExp=See explanation.
|AnswerAExp=The use of [[flumazenil]], when a [[benzodiazepine]] ([[BZD]]) is co-ingested with [[tricyclic antidepressants]] ([[TCA]], often manifests with seizures.
|AnswerB=Chest pain
|AnswerB=Chest pain
|AnswerBExp=Chest pain is not an adverse effect of [[flumazenil]] use in this scenario.
|AnswerBExp=Chest pain is not an adverse effect of [[flumazenil]] use in this scenario.
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|AnswerE=Acalculous cholecystitis
|AnswerE=Acalculous cholecystitis
|AnswerEExp=Acalculous cholecystitis is not an adverse effect of [[flumazenil]] use in this scenario.
|AnswerEExp=Acalculous cholecystitis is not an adverse effect of [[flumazenil]] use in this scenario.
|EducationalObjectives=The use of [[flumazenil]], when a [[benzodiazepine]] ([[BZD]]) is co-ingested with [[tricyclic antidepressants]] ([[TCA]], often manifests with seizures.  The seizure is not believed to be a side effect of [[flumazenil]] itself, rather one of [[tricyclic antidepressants]] that occurs when the effect of a [[benzodiazepine]] is reversed.
|References=Spivey WH. Flumazenil and seizures: analysis of 43 cases. Clin Ther. 1992; 14(2):292-305.<br>
Haverkos GP, DiSalvo RP, Imhoff TE. Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother. 1994;28(12):1347-9.
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=benzodiazepine, tricyclic antidepressant, flumazenil, seizure, adverse drug reaction, side effect, congestion, mixed overdose, suicide
|WBRKeyword=Benzodiazepine, Tricyclic antidepressant, Flumazenil, Seizure, Mixed overdose, Suicide
|Approved=Yes
|Approved=Yes
}}
}}

Revision as of 22:25, 3 November 2014
Author [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pharmacology
Sub Category SubCategory::Neurology
Prompt [[Prompt::A 28-year-old man is brought to the emergency department for excessive somnolence and impaired motor function. Suspecting a benzodiazepine overdose, flumazenil is immediately administered. A few seconds following the administration of flumazenil, the patient’s wife arrives to the emergency department and confirms that her husband likely attempted suicide by ingesting a handful of her anxiety pills which include lorazepam and fluoxetine. Which of the following symptoms will the patient most likely experience following the administration of flumazenil?]]
Answer A AnswerA::Seizure
Answer A Explanation [[AnswerAExp::The use of flumazenil, when a benzodiazepine (BZD) is co-ingested with tricyclic antidepressants (TCA, often manifests with seizures.]]
Answer B AnswerB::Chest pain
Answer B Explanation [[AnswerBExp::Chest pain is not an adverse effect of flumazenil use in this scenario.]]
Answer C AnswerC::Excessive sedation
Answer C Explanation [[AnswerCExp::Flumazenil is expected to reverse the excessive sedation that is caused by BZDs.]]
Answer D AnswerD::Renal failure
Answer D Explanation [[AnswerDExp::Renal failure is not an adverse effect of flumazenil use in this scenario.]]
Answer E AnswerE::Acalculous cholecystitis
Answer E Explanation [[AnswerEExp::Acalculous cholecystitis is not an adverse effect of flumazenil use in this scenario.]]
Right Answer RightAnswer::A
Explanation [[Explanation::Flumazenil is a GABAA receptor antagonist used primarily for the treatment of benzodiazepine overdoses. Flumazenil should be used carefully in patients who have a history of seizures, such as epilepsy, or when there is suspicion of a mixed overdose. The use of flumazenil, when a benzodiazepine (BZD) is co-ingested with tricyclic antidepressants (TCA, often manifests with seizures, a side effect of tricyclic antidepressants. The seizure is not believed to be a side effect of flumazenil itself, rather one of tricyclic antidepressants that occurs when the effect of a benzodiazepine is reversed.

Educational Objective: The use of flumazenil, when a benzodiazepine (BZD) is co-ingested with tricyclic antidepressants (TCA, often manifests with seizures. The seizure is not believed to be a side effect of flumazenil itself, rather one of tricyclic antidepressants that occurs when the effect of a benzodiazepine is reversed.
References: Spivey WH. Flumazenil and seizures: analysis of 43 cases. Clin Ther. 1992; 14(2):292-305.
Haverkos GP, DiSalvo RP, Imhoff TE. Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother. 1994;28(12):1347-9.]]

Approved Approved::Yes
Keyword WBRKeyword::Benzodiazepine, WBRKeyword::Tricyclic antidepressant, WBRKeyword::Flumazenil, WBRKeyword::Seizure, WBRKeyword::Mixed overdose, WBRKeyword::Suicide
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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