Management of Zolpidem Overdose
Zolpidem overdose should be managed with general supportive care including airway protection, monitoring of vital signs, and consideration of flumazenil as a specific antidote, though gastric lavage may be appropriate in early presentations. 1
Immediate Assessment and Stabilization
Clinical Presentation
- Expect impairment of consciousness ranging from somnolence to coma, with potential cardiovascular and/or respiratory compromise 1
- Drowsiness is the most common manifestation, typically occurring at doses of 140-440 mg (14-44 times the therapeutic dose) 2
- Coma and respiratory failure can occur but are relatively uncommon in isolated zolpidem overdose 2, 3
- Pulmonary edema may develop, evidenced by white foam in the airway 4
Critical Monitoring Parameters
- Monitor respiration, pulse, blood pressure, and level of consciousness continuously 1
- Blood concentrations above 1.6-7.7 mg/L have been associated with fatal outcomes 4
- Symptoms typically remit rapidly in 91% of cases with supportive care alone 2
Treatment Algorithm
Primary Interventions
- Administer general symptomatic and supportive measures as the foundation of treatment 1
- Perform immediate gastric lavage where appropriate (early presentation) 1
- Administer intravenous fluids as needed for hemodynamic support 1
- Withhold all sedating drugs following overdose, even if excitation occurs 1
Specific Antidote Consideration
- Flumazenil is an effective antidote that reduces zolpidem's sedative-hypnotic effects 1, 3
- Flumazenil successfully reverses disturbances of consciousness in both mono- and combined intoxications 3
- Important caveat: Flumazenil administration may contribute to neurological symptoms including convulsions 1
- Use flumazenil judiciously, weighing the risk of seizures against the benefit of reversing CNS depression 1, 3
Management of Complications
- Treat hypotension and CNS depression with appropriate medical interventions 1
- Provide respiratory support as needed, particularly in cases with respiratory compromise 1, 2
- Hemodialysis is not effective, as zolpidem is not dialyzable 1
Special Considerations Based on Co-Ingestions
Combined Intoxications Require Enhanced Vigilance
- Co-ingestion with other CNS depressants, psychotropic drugs, or alcohol dramatically increases severity 5, 3
- Coma can occur at doses as low as 100-150 mg when combined with other substances 3
- 44% of patients with zolpidem overdose combined with other medications or alcohol required ICU admission 5
- Monitor patients with combined intoxications for approximately 24 hours 3
Multiple Drug Ingestion Protocol
- Always consider the possibility of multiple drug ingestion in overdose cases 1
- Co-ingestion with over-the-counter medicines increases ICU admission risk 3.3-fold 5
- Co-ingestion with other psychotropics (antidepressants/mood stabilizers) increases ICU admission risk 3.1-fold 5
- Co-ingestion with ethanol increases ICU admission risk 2.1-fold 5
Prognosis and Disposition
Expected Outcomes
- Isolated zolpidem overdose is generally benign and requires no specific therapeutic measures beyond supportive care 2, 3
- Single-drug poisonings with up to 40 times the therapeutic dose (400 mg) typically produce only mild symptoms 3
- The acute toxicity of zolpidem is markedly less pronounced than short-acting benzodiazepines like triazolam or midazolam 3
When to Consider ICU Admission
- Presence of coma or respiratory failure 2
- Co-ingestion with other medications or alcohol 5
- Cardiovascular compromise 1
- Persistent CNS depression despite supportive measures 5