medically induced coma after drug overdose medically induced coma after drug overdose

An analysis of reports of serious adverse reactions of cephalosporins in the French Pharmacovigilance database from 1987 to 2017 revealed that 30.3% of these were encephalopathies (14). CT is widely available and has the advantages of being rapid and relatively resistant to mild degrees of patient motion. Exceptions include drugs with direct CNS toxic effects, such as cyanide or carbon monoxide, which impair the ability to adequately oxygenate the brain. Benzodiazepines can cause decrease in cerebral blood flow and cerebral metabolism, the distribution of which correlates with density of benzodiazepine binding sites. (4; 6%). The reason for that is slowly tapering off the drug lessens the likelihood of relapse, he said, adding going into a medically induced coma is "very extreme" and would typically only ever . For example, benzodiazepines and opiates commonly cause respiratory suppression; amphetamines and cocaine cause hypertension, tachydysrhythmias, and myocardial infarction; and tricyclic antidepressants (TCA) may cause conduction block. Review of literature shows that phenobarbital for the management of seizures in newborns and children might be associated with poisoning, particularly if therapeutic drug monitoring is not used (08). Neurology 2021;96(18):864-7. The term coma, as defined in the classic work of Plum and Posner, is reserved for patients who are in a state of unarousable psychologic unresponsiveness (15). Removal of the unabsorbed drug. The hallmark of a GHB intoxication is the temporary loss of consciousness i.e., coma associated with hypoventilation, mild hypothermia, and bradycardia. It can have a variety of causes, including traumatic head injury, stroke, brain tumor, or drug or alcohol intoxication. The causes are varied and may be toxic, metabolic, degenerative, inflammatory, vascular, or posttraumatic. Just ask Dr. Albert Castellon, MD. During a spinal tap, a health care provider inserts a needle into the spinal canal and collects a small amount of fluid for analysis. His housemate found him unconscious on the sofa at 10am the previous Sunday. The vital signs of the patient may also reflect drug intoxication. Over a 30-day ICU time period, the incremental cost of persistent daily delirium or coma attributable to increased service intensity is about $18,000. Jain KK. Discontinuation of the offending drug. Chronic use of metronidazole, an antimicrobial agent, can cause neurotoxic effects including encephalopathy with impairment of consciousness and brain lesions demonstrated on MRI. The initial goals in the management of the comatose patient are directed toward respiratory and cardiovascular stabilization. Life Sci 2014;97(1):37-44. Direct effect of drugs on the brain. The pupils are typically small but reactive and dilate widely in response to a narcotic antagonist (eg, naloxone). Drugs producing hypoglycemia. Noncardiogenic pulmonary edema (NCPE), which affects 0.3-2.4% of heroin overdoses, generally lasts 24-48 hours and responds to supportive care. Several cases of coma due to therapeutic use of valproic acid in epilepsy as well as to its overdose have been reported in literature. Listen to MedLink on the go with Audio versions of each article. Cephalosporins. Focused use of drug screening in overdose patients increases impact on management. Nobody wants to experience painful or unpleasant withdrawal symptoms, but an extreme measure like medically induced coma is a dangerous quick fix/avoidance strategy. These patients present with tachycardia, hypertension, fever (due to blocked exocrine secretions), dry skin, ileus, and urinary retention, but the presentation with these features can be variable. Coma rarely lasts more than a month and usually ends sooner. Loss of consciousness is marked simultaneously by an increase in low-frequency EEG power (< 1 Hz), the loss of spatially coherent occipital alpha oscillations (8-12 Hz), and the appearance of spatially coherent frontal alpha oscillations, which reverse with recovery of consciousness (10). So yes I do think the drugs can do more damage after during icu treatment. The most common bloodborne pathogen identified was hepatitis C virus; 41 (37%) patients had a current or previous hepatitis C virus infection documented in the medical record . Polytherapy with antiepileptic drugs where coma may result from drug interaction after addition of valproic acid. Alcohol: combination with sedative-hypnotics Anesthetics: eg, propofol Direct effect from prolonged use or overdose of following drugs: - Anticholinergic drugs - Antipsychotics - Barbiturates - Benzodiazepines in combination with other CNS depressants - Cephalosporins - Cholinergic drugs - Lithium overdose - Metronidazole - Opioids - Sympatholytic drugs - Tricyclic antidepressants - Valproic acid - Vigabatrin, Secondary effect of other drug-induced adverse effects, - Drug-induced hypoglycemia, eg, insulin - Drugs-induced serotonin syndrome - Drug-induced diabetes insipidus with hyperosmolar coma - Drug-induced hyperosmolar non-ketotic diabetic coma: eg, prednisone - Drug-induced hepatic encephalopathy, eg, 5-fluorouracil - Drug-induced cerebrovascular disorders: cerebral vasculitis, cerebral hemorrhage - Drug-induced cardiovascular disorders - Drug-induced hyponatremia - Drug-induced renal disorders: uremic encephalopathy - Neuroleptic malignant syndrome, Poisons: eg, cyanide, carbon monoxide Recreational drugs and drug abuse, - MDMA (Ecstasy) - Gamma-hydroxybutyric acid - Methaqualone - Psychedelics, eg, LSD - Synthetic cannabinoids. Other variables affecting outcome include secondary injuries caused to the brain, such as cerebral infarction from a cocaine-induced vasculitis, global anoxic injury from prolonged impaired ventilation with hypotension as may be seen with opiate overdose, or hepatic encephalopathy with hyperammonemia seen in fulminant liver failure caused by acetaminophen overdose. Depends on cause: The outcome from coma depends on many things including the cause of the coma the duration of coma and how much brain damage has occurred. CNS downers reduce basal metabolism and heart rate while still slowing the heart rhythm and breathing. Manifestations of muscarinic stimulation include excessive salivation, sweating, lacrimation, urination and defecation, muscle fasciculation, miosis, bradycardia, and hypotension. Elevation of serum lactate level with high mixed venous saturation suggested possible mitochondrial dysfunction, prompting use of barbiturate-induced coma to reduce cerebral metabolic demand. If a person is in a coma because of drugs or alcohol or other non-medical causes, they need emergency medical treatment. Patients develop a decreased level of consciousness and sometimes become comatose. Many patients who overdose on drugs or alcohol also can recover once the substance clears their system. Facial expressions etc head turning. During an overdose, the body experiences CNS depression, which can result in decreased rate of breathing, decreased heart rate, and loss of consciousness, possibly leading to coma or death. J Neurol Sci 2018;392:137-8. That plan is a biomedical plan, a psychosocial plan, a mental health plan, and a support plan, as well as a continuity of care plan.. Probably a locked-in care setting, because of his tendency to wander. Here's how it works: A patient arrives in the emergency room after an overdose, car accident or other trauma that caused extensive brain injury. The purpose of a rapid detox is just that to have the patient detoxed, Dr. Castellon said. Case summary: A 49-year-old male ingested an overdose of duloxetine approximately 2 hours before presentation to the emergency department. Hands finger movements. At vero eos et accusamus et iusto odio dignissimos ducimus qui blanditiis praesentium voluptatum deleniti atque corrupti quos dolores et quas. Occasionally these findings may be drug-induced. He had been in an induced coma for four days after suffering a near fatal overdose from a mix of heroin and prescription drugs, a particularly dangerous combination that is known to suppress breathing. Emergency medical services responders, trained laypeople and the general public (with the support of 911 emergency dispatcher instructions) can administer naloxone to prevent cardiac arrest. Plum F, Posner JB. The term "drug-induced encephalopathy" is used when the cause is use or abuse of therapeutic drugs as well as illicit or recreational drugs, but it may be secondary to other drug-induced disorders, such as hepatic encephalopathy, hypertensive encephalopathy, uremic encephalopathy, hyponatremia, and hypoglycemia ( 11 ). This article describes coma due to drug intoxication, including recreational and illicit drugs as well as more commonly used medications such as antidepressant, antiepileptic, and psychotropic medications. The age group can, however, provide insight to the type of drug intoxication that may have occurred. Dr. JAMES BERNAT (Dartmouth Medical School): The medically induced coma is intended to reduce the metabolic demand of the brain cells. Miscellaneous drugs with case reports of coma. Tricyclic antidepressant overdose. Calcium channel-blockers and beta-blockers are the main suspects, although such dysrhythmias can be caused by digoxin overdose or massive overdoses of either local anesthetics or cocaine. University of Toronto psychologist and author Jordan Peterson, who reportedly struggled with benzodiazepine dependency, made headlines in February 2020 when he went to Russia to seek coma detox treatment. The procedure involved medically inducing a coma that lasted for eight days, according to news reports. Even death may occur. The major site of action of the benzodiazepines is the reticular activating system; however, in high doses generalized cortical depression may occur, which contributes to stupor. Needle marks should be sought in suspected intravenous drug use, although heroin may also be sniffed, and even first-time users can present in severe states. There are no hard and fast rules because drug-induced coma may resemble metabolic encephalopathy on one hand and may induce structural lesions in the brain. A 17-year-old male was brought into the emergency department by his friends after a seizure. Carbon monoxide poisoning typically occurs with exposure to fires, suicide attempts, or defective room ventilation. Alcohol is a common agent of intoxication causing encephalopathy, affecting nearly all age groups and genders. An example of therapy guided by drug-specific urinary findings in this study was administration of bicarbonate for overdose with tricyclic antidepressants. Abnormal movements often accompany coma due to toxic-metabolic causes, whereas coma due to structural lesions is accompanied by abnormal posturing. After surviving a near-fatal overdose in 2019, Aeris Kurtis Finch was placed in a medically induced coma, left. A patient can be put in a medically induced coma with the administration of barbiturate drugs or by lowering the body temperature to 32-34 C. Drug-induced cerebral vasculitis, often associated with drug abuse, is an example of complications that may be associated with a comatose state. The key to prevention of drug poisoning is education at multiple levels. According to the U.S. Conference of Catholic Bishops, the church believes that "patients should be kept . This should be repeated multiple times until the aspirate becomes clear. Doctors do everything they can to stabilize the patient, but his brain may have suffered irreversible damage. Isopropyl alcohol ingestion, found in rubbing alcohol, may cause rapidly progressive coma, hemorrhagic gastritis, and circulatory collapse. The first stage consists of CNS effects: encephalopathy, coma, and seizures. Overdose of opioids causes the triad of coma, respiratory depression, and pinpoint pupils. Hyperbaric oxygen. These are commonly used to control agitation and psychosis, but significant side effects can occur with high doses. Jain KK. One notable exception would be an acute basilar thrombosis, and if this diagnosis is entertained, options to further evaluate this include CT angiography, MRI with diffusion-weighted imaging, and MRA. Lisa Marie Presley, 54, died Thursday while hospitalized in critical condition after reportedly going into cardiac arrest. We offer 100% confidential and individualized treatment, Kristina Robb-Dover is a content manager and writer with extensive editing and writing experience read more. Get Medical Treatment. There's no official term for the problem, but it's being called a "prolonged" or "persistent" coma or unresponsiveness. Pathomechanism. But due to testing limitations and other confounding factors, such as therapeutic hypothermia, predicting an outcome may be biased and premature. If an intracerebral hemorrhage has developed, strict blood pressure control and correction of any underlying coagulopathy are imperative. This is when a patient is under general anesthesia for several hours while they are given the opiate receptor blocker naltrexone., Why send the patient into a comatose state? Signs and symptoms of a drug overdose include: Unconsciousness, coma No gag reflex, inability to prevent choking (especially from vomit) Abdominal pain, nausea, vomiting, and diarrhea Blood in vomit or bowel movements Sleepiness Confusion Skin can be cool and sweaty or hot and dry Seizures, convulsions Most of the available treatments are safe and effective for managing patients with drug-induced coma but some neurologic sequelae may not be reversible. A medically induced coma for the purpose of detox is otherwise known as rapid detox. Dr. Castellon said. Poisoning, usually involving an overdose of drugs that depress the nervous system, such as narcotics, tranquilizers or alcohol. Anesthesia is a reversible drug-induced coma and not a state of deep sleep. Swiss Med Wkly 2015;145:w14242. Outlook. A phone call to a family member or housemate can sometimes be helpful, especially if it reveals available drugs, history of previous overdose or illicit drug use, and history of underlying relevant illness (ie, diabetes, metabolic disorder, depression, etc.). Combination clearance therapy and barbiturate coma for severe carbamazepine overdose. CT and MR imaging findings in methanol intoxication manifesting with BI lateral severe basal ganglia and cerebral involvement. Some patients recover following discontinuation of the drug. A study on patients presenting with drug-induced coma showed that emergency department physicians underestimate diagnoses of GHB intoxication based on clinical observations alone (17). Propofol is attractive due to its short half-life, allowing for interruption of infusions to assess the neurologic state of the patient. Glutethimide toxicity. In a recent interview, Dr. Castellon shared his expertise as it relates to the safety and efficacy of medically induced coma detox. But the treatment is controversial although some treatment centers claim it helps people avoid withdrawal symptoms altogether and improves their prospects of recovery. Brain scans Imaging tests help pinpoint areas of brain injury. Parents need to be educated to the risks of prescription medications if accidentally ingested by a child, and childproof caps should be utilized. Disorders of consciousness include a spectrum of clinical states, with coma at the most severe end of the spectrum. Toxicodynetics in nordiazepam and oxazepam overdoses. Benzodiazepines potentiate the effects of other CNS depressants. Dr. Castellon also acknowledged that while a pain-free withdrawal may sound appealing at first there are too many possibilities for complications, as well as increased likelihood of relapse., How a Painless Detox May Increase Relapse Risks. Overdose can cause sedation, respiratory depression, and coma. When patients are in a medically induced coma, the brain is quiet for up to several seconds at a time, punctuated by short bursts of activity. Posts: 52. friend in an induced coma/ drug overdose. Hypoglycemia should be ruled out immediately, and if there is delay in doing so, patients may be treated with glucose infusion preceded by IV thiamine prophylactically. It was determined that he had a cocaine-induced vasoconstriction syndrome, and he was admitted to the intensive care unit for supportive management. The muscle tone in the extremities may be increased with certain agents, such as psychotropic medications (antipsychotics, selective serotonin reuptake inhibitors), even leading to neuroleptic malignant syndrome. But he is proof of that saying, that drug addicts will either end up in jail, in institutions or dead. A case report of methadone-associated hypoglycemia in an 11-month-old male. Drug-induced cardiovascular collapse with cardiac arrest may lead to coma due to cerebral ischemia/hypoxia if resuscitation is not carried out promptly. Response to emergency therapy is helpful in the differential diagnosis, eg, response by recovery after intravenous glucose indicates hypoglycemic coma. Valproic acid overdose can be treated with L-carnitine therapy, which can enhance the excretion and help to prevent fatal liver failure. Member. The nicotinic effects include sympathetic stimulation with resulting tachycardia and hypertension. Respiratory decompensation occurs either because of CNS suppression or secondary to pulmonary edema. Intoxication, due to ethylene glycol, commonly used as antifreeze, appears to progress in three discrete stages. Accidental ingestion of anticholinergic medications (eg, diphenhydramine) can lead to the anticholinergic syndrome, with blockade of parasympathetic receptors leading to unopposed sympathetic activity. Carnitine deficiency. If there are any concerns about content we have published, please reach out to us at marketing@fhehealth.com. That is the theory anyway., The Dangers of a Medically Induced Drug or Alcohol Detox. A drug-induced coma (alcohol, GHB, ketamine) in which the subject is fully unconscious strongly resembles general anesthesia. The third stage involves progressive renal failure and death. Doctors in Catholic hospitals practice palliative sedation even though the Catholic Church opposes aid-in-dying. CNS Neurol Disord Drug Targets 2021;20(2):174-80. Vasculitis associated with drugs is usually hypersensitivity vasculitis, which can be considered an explanation of acute neurologic deficits resulting from the administration of drugs that normally do not affect the cerebral blood vessels. A coma-induced detox, on the other hand, takes place in a different medical context: When an addicted person is about to begin drug or alcohol withdrawal. Infections, either systemic or primary to the CNS, need to be addressed rapidly; bacterial meningitis continues to have a significant morbidity and mortality rate associated with it, as do certain viral infections (eg, Herpes simplex virus, West Nile virus). World Neurosurg 2020;135:e664-70.**. In a patient without overt seizures but continued unexplained unresponsiveness, nonconvulsive seizures should be considered. Response by recovery after intravenous glucose indicates hypoglycemic coma, response to naloxone usually indicates opiate drug overdose, and response to flumazenil indicates benzodiazepine overdose. Valproic acid. The term encephalopathy refers to generalized dysfunction of the brain with manifestations varying according to the involvement of brain structures, and coma may occur in severe cases. Cariad has been in an induced coma since October 31 after attempting suicide Credit: Caters News Agency. Camurcuoglu E, Halefoglu AM. (female) Join Date: Jul 2008. Brain imaging to rule out a primary brain lesion. treatment for a substance abuse and/or mental health, No responses to stimuli apart from reflex movements, Depressed brainstem reflexes such as pupils not responding to light. Lithium overdose. Physostigmine is used for reversal of anticholinergic toxicity, but it should be reserved for refractory cases because of its adverse effects that include seizures and cardiac rhythm disturbances. FHE Health Is Open With Enhanced Safety Protocols Read more. Agulnik A, Kelly DP, Bruccoleri R, et al. Drug overdoses can be accidental or intentional. A comatose patient, who was admitted in respiratory failure and shock after the intentional ingestion of about 280 extended-release 200 mg carbamazepine tablets with a peak serum concentration of 138 g/mL, developed seizures with an EEG pattern of stimulus-induced rhythmic, periodic, or ictal discharges, suggestive of significant cortical dysfunction (01). Normal doses of some drugs may produce overdose effect in some circumstances, such as drug interactions and renal failure, impairing excretion of the drug. Outcome of acute heroin overdose requiring intensive care unit admission Induced emesis is contraindicated in a patient with a depressed level of consciousness, but gastric lavage may be performed if the patient has the airway secured with an endotracheal tube. First, what is a coma, and what happens in a comatose state? Other parameters include imbalances of carbon dioxide, sodium, phosphorus, calcium, and magnesium. Raised intracranial pressure and papilledema is more likely in intracranial space-occupying lesions. Coma is unresponsiveness from which the patient cannot be aroused and in which the patient's eyes remain closed.Impaired consciousness refers to similar, less severe disturbances of consciousness; these disturbances are not considered coma. Reported cases of coma mimicking brain death secondary to baclofen overdose have described a duration of coma of up to 7 days [3, 4]. Elderly persons are the most likely group to be exposed to polypharmacy, and the interaction of different medications becomes even more important. Coma due to structural lesions usually progresses, whereas toxic or metabolic coma is usually stable or improves. Because the focus of this article is on coma due to drug intoxication and not lesser degrees of disturbances of consciousness, reference to encephalopathy will be given only where it is relevant. A single seizure rarely produces coma, but status epilepticus can because repeated seizures can prevent the brain from recovering in between seizures. Therefore, the term coma due to drug intoxication is preferred when it is due to drug overdose, inappropriate use, or as an adverse reaction. Because many drugs that cause slow rhythms also depress myocardial function, patients who've overdosed on them will have marked hypotension. Drug intoxication should be suspected in any patient presenting with extreme drowsiness and coma-altered mental state without another overt etiology. The pathologic physiology of signs and symptoms of coma. Generally, older patients metabolize medications more slowly and, thus, the elderly population may be at risk of side effects from psychoactive medications, and the duration of effect may be more prolonged. Methamphetamine overdose. Drug-induced coma should be differentiated from coma due to structural lesions of the brain and metabolic encephalopathies. The pupillary exam may be abnormal; for example, opiates often cause profound miosis, whereas sympathomimetics cause mydriasis. Can emergency department clinicians diagnose gamma-hydroxybutyrate (GHB) intoxication based on clinical observations alone? Pupil reactivity is usually spared in toxic-metabolic coma with exception of drugs such as atropine, which dilate the pupils. The 19-year-old took an overdose on Halloween and has been in an induced coma ever since. Coma due to acute intoxication with synthetic cannabinoids. An emergency EEG should be considered in cases with ongoing seizures with possible status epilepticus and in selected cases in which nonconvulsive status epilepticus is being considered. overdose, many references indicate the half-life of baclofen is approximately 2-4 h, but in overdose, the duration of effect far exceeds the recommended five half-life calculation [3]. Lumbar puncture if there is suspicion of meningoencephalitis. Barbiturates. This usually happens within 20 seconds after the heart stops beating. The problem is that with addiction disorders there needs to be a comprehensive plan to decrease the likelihood of relapse., Dr. Castellon explained that a comprehensive plan for treating addiction is more than just about detox withdrawal symptoms. Pediatrics 2019;144(2):e02182690.**. A combination of therapies was used in this case, including lipid emulsion therapy, plasmapheresis, hemodialysis, continuous venovenous hemodialysis, and endoscopic intestinal decontamination. Ann Pharm Fr 2017;75(3):163-71. While naloxone is useful, it is still important to get medical help. He just didn't wake up. Pupillary responses, however, are still preserved, except in cases of extreme doses. Coma is a medical emergency. Other drugs that can cause this syndrome include atropine, certain agents used for treatment of Parkinson disease, muscle relaxants, neuroleptics, and tricyclic antidepressants. Rare instances of coma have been reported with selected drugs: cefepime, colloidal silver, lamotrigine, intranasal desmopressin with severe hyponatremia, chloroquine, baclofen, tramadol, acyclovir, primidone, bromide, and over-the-counter hypnotics. The mechanisms underlying anesthesia-induced loss of consciousness are not clearly defined. Sometimes a coma is induced in patients who are at high risk of brain injury from incidents such as physical trauma, drug overdose or life-threatening seizures. Young adults are more likely to experiment with recreational drugs but are also at risk for suicide attempts, as are those in their middle ages. Correction of acid-base disturbances. Hyperammonemia has been reported in valproic acid-induced coma. Doctors sometime induce . Another example is coma with intracerebral hemorrhage due to use of anticoagulants. Overdose of various opiates can cause coma, and this may occur in the hospital setting, such as with unintended overdose of morphine sulfate or with recreational drug use, such as with heroin use. He supervises the drug and alcohol detox process for patients at FHE Health and is well-versed in best practices for medically supervised withdrawal. Encephalopathy may be associated with other neurologic manifestations and does not necessarily lead to coma. Acetaminophen level is often not included in standard toxicology screens, but if this drug is suspected based on the history, it should be specifically requested. This manifests like barbiturate overdose, but hallucinations and agitated delirium are more common, and with higher doses there may be seizures and coma. Drug-induced organic delusional syndrome: 292.11, Poisoning by drugs, medicinal and biological substances: 960-979, Adverse effect to correct medicinal substance properly administered: 995.2, Poisoning by drugs, medicaments and biological substances: T36-T50, For information on discounts, see Plans & Pricing, Alcohol abuse and its neurologic complications, Illicit drug use: neurologic complications, Metabolic encephalopathy and metabolic coma. Depending on how long the coma lasts and the severity of injury to the brain, emerging from a coma may take days or weeks, and an individual may go through stages of consciousness before they are responsive. A cerebrovascular event must be considered early, as the treatment window is narrow. Antipsychotic medications. This is usually due to drugs that act mainly on the nervous system such as sedative hypnotics. If one of our articles is marked with a reviewed for accuracy and expertise badge, it indicates that one or more members of our team of doctors and clinicians have reviewed the article further to ensure accuracy. With concomitant ethanol ingestion, respiratory depression becomes much more dramatic, and patients may become comatose and require ventilatory support. While a totally painless detox is rarely attainable, many people have found relief for physical and emotional cravings and withdrawal symptoms thanks to a medically supervised detox at a quality treatment center. This causes drowsiness and sometimes leads to coma, often with seizures. Flumazenil is a benzodiazepines antagonist and may be used in cases of benzodiazepines overdose (0.2 mg intravenous over 30 seconds; additional doses up to 0.5 mg may be repeated every minute, up to a cumulative dose of 3 mg; it may be repeated in 20 minutes, but the total dose should not exceed 3 mg in any given hour). Anderson SAR, Oprescu AM, Calello D, et al. Most comas don't last more than two to 4 weeks. Common clinical manifestations are discussed, as well as involvement of organs other than the brain, which may also contribute to the patients coma. Intravenous contrast is most often not required in the acute setting, as a CNS event severe enough to cause coma is most likely to be seen on a noncontrast imaging study. The good news is detox doesnt have to be as scary or painful as some might think. They are also referred to as synthetic pot or spice, but are not approved for human use. Clues to the presence of a vascular event include the timing, which is usually sudden or rapidly progressive, with focal neurologic signs on examination. Two syndromes occur after acute carbon monoxide poisoning: persistent neurologic sequelae and the interval form of CO poisoning. Reflex eye movements are usually intact in toxic-metabolic coma except with overdose of some drugs such as phenytoin. Hemodialysis is not effective, however, for tricyclic antidepressant overdose, but serum alkalinization with intravenous boluses of sodium bicarbonate should be performed, which helps to reduce QRS widening. Toxicodynetic studies show that nordiazepam is not a cause of coma even in large overdose, whereas oxazepam causes coma only at a very high dose.