What to order for a somnolent (drowsy) patient?

From the Guidelines

For a somnolent patient, immediate assessment and intervention are crucial to prevent progression to stupor or coma, and I recommend a comprehensive approach including airway, breathing, and circulation evaluation, followed by a rapid neurological assessment and appropriate diagnostic tests, as outlined below. The goal is to identify and treat the underlying cause of somnolence, which could include metabolic disorders, drug effects, structural brain lesions, or infections 1.

Initial Assessment and Intervention

• Assess airway, breathing, and circulation (ABCs) to ensure patient stability.
• Perform a rapid neurological evaluation to identify potential causes of somnolence.
• Order a comprehensive metabolic panel, complete blood count, arterial blood gas, toxicology screen, and blood glucose measurement to identify metabolic causes.
• Obtain neuroimaging with CT or MRI of the brain urgently if a structural cause is suspected.

Specific Interventions Based on Suspected Cause

• If hypoglycemia is suspected, administer 50ml of 50% dextrose intravenously.
• For suspected opioid overdose, give naloxone 0.4-2mg IV/IM/intranasal.
• If benzodiazepine overdose is likely, consider flumazenil 0.2mg IV over 30 seconds, with repeat doses as needed up to 1mg.
• For suspected Wernicke's encephalopathy, administer thiamine 500mg IV three times daily.

Ongoing Management

• Continuous monitoring of vital signs and neurological status is essential.
• Consider the use of medications approved for hypersomnolence, such as solriamfetol or pitolisant, under the guidance of a sleep specialist and based on individual patient needs and response, as recommended by the American Academy of Sleep Medicine 1.
• Nonpharmacologic management, including sleep hygiene practices and cognitive-behavioral therapy, should also be considered as part of a comprehensive treatment plan.

From the FDA Drug Label

For the reversal of the sedative effects of benzodiazepines administered for conscious sedation, the recommended initial dose of flumazenil injection is 0.2 mg (2 mL) administered intravenously over 15 seconds. The dosage should be individualized based on the patient’s response, with most patients responding to doses of 0.6 mg to 1 mg

For a somnolent patient, flumazenil (IV) can be ordered with an initial dose of 0.2 mg administered intravenously over 15 seconds. The dosage should be individualized based on the patient's response. Most patients respond to doses of 0.6 mg to 1 mg. 2

From the Research

Assessment and Treatment of Somnolent Patients

When dealing with somnolent patients, it's crucial to follow a systematic approach to assess and treat the underlying cause of their excessive sleepiness.

• The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a widely accepted method for immediate assessment and treatment in clinical emergencies 3.
• For somnolent patients, the assessment should include a thorough sleep, medical, and psychiatric history, as well as targeted clinical examinations and the use of actigraphy, polysomnography, and multiple sleep latency testing 4.

Medications and Somnolence

Medications can play a significant role in somnolence, particularly those with somnolence as a potential adverse effect.

• Nearly half of older adults experience somnolence, and the use of medications with potential somnolence adverse effects is common among this population 5.
• Benzodiazepines, a class of psychoactive drugs, can cause severe, harmful psychological and physical dependence, leading to withdrawal symptoms similar to those of alcohol withdrawal 6.

Treatment Options

Treatment for somnolent patients depends on the underlying cause of their excessive sleepiness.

• For central disorders of hypersomnolence, treatment is primarily pharmacologic, with wakefulness-promoting agents such as modafinil, stimulants like methylphenidate and amphetamines, and newer agents designed to improve wakefulness 4.
• Behavioral interventions can provide a useful adjunct to pharmacologic treatment, and targeting the primary disorder is essential when excessive sleepiness is secondary to other conditions 4.