Pediatric emergency medicine trisk 3159 3159

Optimal treatment of significant sedative overdose includes continuous
monitoring in an intensive care unit, often with intubation and ventilator support
as indicated. Flumazenil, a benzodiazepine antagonist, can be administered in
select cases of suspected benzodiazepine ingestion. Its pediatric dose is 0.01 to
0.02 mg/kg IV (max 0.2 mg/dose) and may be repeated to a maximum of 0.05
mg/kg or 1 mg, whichever is less. Indications for flumazenil administration may
be (i) to reverse a witnessed, unintentional benzodiazepine overdose in a young
child or (ii) to prevent airway intubation after an iatrogenic overdose. Flumazenil
must not be given empirically in unknown or intentional overdoses as it may
induce potentially life-threatening seizures.

Opioids
CLINICAL PEARLS
Naloxone, an opioid antagonist, is the first line of therapy for patients
with opioid-induced respiratory depression. Doses as low as 0.2 to 0.4
in opioid-dependent patients may precipitate withdrawal and should be
given cautiously.
In opioid-naive children, the initial naloxone dose is 0.1 mg/kg.
Buprenorphine is a partial opioid agonist which is becoming the
mainstay of medication-assisted therapy for opioid use disorder.
Pediatric toxicity from buprenorphine is similar to toxicity from full opioid
agonists.
Current Evidence
In the past two decades, recreational abuse of insufflated heroin and ingested
prescription opioid analgesics (particularly oxycodone and hydrocodone) has
risen to epidemic proportions in the United States and may be partly responsible
for the first increase in overall drug-related mortality in a generation. In addition,
some opioid-related deaths are likely inadvertent and represent inappropriate
misuse of combinations of alcohol, sedative-hypnotic agents, and prescription
analgesics.
The significant rate of opioid abuse has also given rise to the common

treatment of opioid addiction by the outpatient prescription of buprenorphine (a
partial opioid agonist) which has resulted in the opioid syndrome in toddlers
when they ingest this agent. While the partial agonist behavior of buprenorphine