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Created page with "{{WBRQuestion |QuestionAuthor={{Rim}} |ExamType=USMLE Step 1 |MainCategory=Pharmacology |SubCategory=Neurology |MainCategory=Pharmacology |SubCategory=Neurology |MainCategory=..."
 
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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{Rim}} {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pharmacology
|MainCategory=Pharmacology
Line 20: Line 20:
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|SubCategory=Neurology
|SubCategory=Neurology
|Prompt=A 28 year old male patient who is previously healthy is brought to the emergency department for excessive somnolence, impaired balance, and impaired motor function.  The physician suspects a benzodiazepine overdose.  Flumazenil is quickly administered at the appropriate dose and infusion rate.  A few seconds after administration of flumazenil, the patient’s wife arrives to the emergency department and tells the physician that her husband attempted suicide and in fact ingested excessively two drugs: A benzodiazepine and a tricyclic antidepressant.  Which of the following symptoms will the patient most likely experience following administration of flumazenil in this case of co-ingestion of benzodiazepine and tricyclic antidepressant?
|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?
|Explanation=[[Flumazenil]] should be used carefully in patients who have a previous history of [[seizures]], such as a past medical history of [[epilepsy]], or when there is suspicion of mixed [[overdose]]. In the case when [[benzodiazepine]] ([[BZD]]) is co-ingested with [[tricyclic antidepressants]] ([[TCA]]), the use of flumazenil as an antidote to benzodiazepine to reverse the sedative effects of benzodiazepines can actually expose or unmask the side effect of tricyclic antidepressants, such as seizures, that can occur within only a few minutes of administration of flumazenil.  The seizure is not believed to be a side effect of flumazenil itself, but rather an unmasking of the side effect of the tricyclic antidepressant that is apparent only when the effect of benzodiazepine is reversed by 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.


As a result, seizure risk must always be assessed in patients who require flumazenil use and a risk-to-benefit ratio in those patients must always be considered as to whether flumazenil is to be administered or not.  
As a result a risk-to-benefit ratio in patients must be considered when administering [[flumazenil]].


Educational Objective:
|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.
In the case when benzodiazepine (BZD) is co-ingested with tricyclic antidepressants (TCA), the use of flumazenil as an antidote to benzodiazepine to reverse the sedative effects of benzodiazepines can actually unmask the side effect of tricyclic antidepressants, such as seizures, that can occur within a few minutes of administration of flumazenil.
|References= Spivey WH. Flumazenil and seizures: analysis of 43 cases. Clin Ther. 1992; 14(2):292-305.
 
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.
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=Seizure is a potential adverse event in the case of flumazenil antidote of when co-ingestion of BZD and TCA.
|AnswerAExp=See explanation.
|AnswerB=Chest pain
|AnswerB=Chest pain
|AnswerBExp=Chest pain is not an adverse effect of flumazenil use in this case.
|AnswerBExp=Chest pain is not an adverse effect of [[flumazenil]] use in this scenario.
|AnswerC=Excessive sedation
|AnswerC=Excessive sedation
|AnswerCExp=Flumazenil is expected to reverse the excessive sedation that is caused by BZD.
|AnswerCExp=[[Flumazenil]] is expected to reverse the excessive sedation that is caused by BZDs.
|AnswerD=Renal failure
|AnswerD=Renal failure
|AnswerDExp=Renal failure is not an adverse effect of flumazenil use in this case.
|AnswerDExp=Renal failure is not an adverse effect of [[flumazenil]] use in this scenario.
|AnswerE=Acalculous cholecystitis
|AnswerE=Acalculous cholecystitis
|AnswerEExp=Acalculous cholecystitis is not an adverse effect of flumazenil use in this case.
|AnswerEExp=Acalculous cholecystitis is not an adverse effect of [[flumazenil]] use in this scenario.
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=benzodiazepine, tricyclic, antidepressant, flumazenil, seizure, adverse, drug, reaction, side, effect, coingestion, mixed, overdose
|WBRKeyword=benzodiazepine, tricyclic antidepressant, flumazenil, seizure, adverse drug reaction, side effect, congestion, mixed overdose, suicide
|Approved=No
|Approved=Yes
}}
}}

Revision as of 17:27, 23 July 2014
Author [[PageAuthor::Rim Halaby, M.D. [1] (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pharmacology
Sub Category SubCategory::Neurology
Prompt [[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?]]
Answer A AnswerA::Seizure
Answer A Explanation AnswerAExp::See explanation.
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 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.
Educational Objective: 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.]]

Approved Approved::Yes
Keyword WBRKeyword::benzodiazepine, WBRKeyword::tricyclic antidepressant, WBRKeyword::flumazenil, WBRKeyword::seizure, WBRKeyword::adverse drug reaction, WBRKeyword::side effect, WBRKeyword::congestion, WBRKeyword::mixed overdose, WBRKeyword::suicide
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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