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O'Connell CW, Sadler CA, Tolia VM, Ly BT, Saitman AM, Fitzgerald RL. 
“Overdose of etizolam: the abuse and rise of a benzodiazepine analog”. 
Ann Emerg Med. 2015 Apr 25;65(4):465-6.
[letter to the editor, case study ]

Etizolam is a theinodiazepine, structurally different but pharmacologically similar to benzodiazepines with gammaaminobutyric acid type A receptor agonism.1 It is approved for pharmaceutical use in some areas but is available for Internet purchase in the United States and many other countries for research purposes. It is increasing in popularity as a recreational “research chemical.” Recent unpublished data from the American Association of Poison Control Centers in the United States has shown an incremental increase in etizolam-related cases each year since 2011, with 41 cases reported as of August 2014. There is little reported in the English literature about the toxic effects of etizolam overdose.

A 31-year-old man presented to our emergency department (ED) after being found unresponsive and bradypneic next to an empty syringe of alleged heroin. By reports, he had also ingested a large quantity of etizolam tablets throughout the day. Out-of-hospital intranasal naloxone, dose of 2 mg, resulted in partial reversal, with improvement of respiratory rate but minimal improvement of his mental status. On arrival to the ED, vital signs were as follows: pulse rate 115 beats/ min, respiratory rate 12 breaths/min, blood pressure 132/64 mm Hg, temperature 98.9F (37.2 C), and pulse oximetry 100% on nonrebreather mask at 15 L/min. He arrived obtunded, he moaned, and he localized painful stimuli. Pupils were pinpoint. Given his profound sedation despite naloxone administration, a trial of 0.2 mg of intravenous flumazenil was used to attempt reversal of etizolam and potentially avoid intubation and limit need for expanded diagnostics. It caused immediate and complete reversal. Initial remarkable laboratory diagnostics included pH 7.30 and pCO2 61 mm Hg on a venous blood gas test, creatinine level of 1.19 mg/dL, glucose level of 116 mg/dL, and WBC count of 18.6  1000/mm3. Ethanol, acetaminophen, and salicylates were not detected. ECG demonstrated narrow complex sinus tachycardia. Standard qualitative urine drug screen result was positive for opiates and benzodiazepines. Two hours after arrival, the patient once again became somnolent and bradypneic; he received an additional 2 mg of naloxone intravenously, with complete return to full alertness. He was discharged home neurologically intact after approximately 8 hours of observation.
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