What is the appropriate emergency management for a Baclofen overdose?

Baclofen Overdose: Emergency Management

Immediate Airway and Respiratory Management

Secure the airway immediately and provide bag-mask ventilation when respiratory depression is present—this is the definitive life-saving intervention that takes absolute priority over any pharmacologic therapy. 1

• Open the airway using head-tilt/chin-lift or jaw-thrust maneuver as the first physical action. 1
• Begin rescue breathing or bag-mask ventilation without delay; continue until spontaneous breathing returns. 1
• Proceed to endotracheal intubation if Glasgow Coma Scale ≤ 8 or protective airway reflexes are absent, as baclofen overdose commonly presents with profound coma and flaccid paralysis. 2, 3, 4
• Activate emergency response systems immediately without waiting to assess the patient's response to any intervention. 1

Clinical Recognition

Baclofen overdose presents with a distinctive constellation of findings that emergency physicians must recognize:

• Dose-related alteration in consciousness progressing to profound coma with absent brainstem reflexes, which can mimic brain death. 3, 4, 5, 6
• Flaccid paralysis and hyporeflexia rather than the spasticity typically seen in other CNS depressant overdoses. 3, 4
• Fixed dilated pupils may be present, further mimicking brain death. 4
• Severe respiratory depression requiring mechanical ventilation is common. 4, 5, 6
• EEG may show burst suppression or significantly reduced amplitudes, but cerebral bioelectric activity remains present, distinguishing this from true brain death. 4, 5

A critical pitfall: Patients brought in after apnea or cardiopulmonary resuscitation may be misdiagnosed as post-hypoxic encephalopathy rather than baclofen intoxication. 6

Monitoring Requirements

• Maintain continuous cardiac monitoring with serial ECGs to detect autonomic disturbances including hypertension, hypotension, and tachycardia. 7, 8
• Observe in a monitored setting until vital signs normalize and risk of recurrent toxicity is low. 1, 7
• Seizures may occur and require antiepileptic medications as indicated. 8, 3

Supportive Care Protocol

There is no specific antidote for baclofen overdose; treatment is entirely supportive with mechanical ventilation and hemodynamic stabilization. 3, 5, 6

• Provide intensive supportive care and time—patients can achieve complete neurological recovery within 72 hours despite appearing brain dead on presentation. 6
• Administer benzodiazepines for seizure control if needed. 8, 3
• Plasma baclofen levels are not reliably correlated with CNS depression severity and should not guide management decisions. 5, 6
• Imaging studies (CT/MRI) are typically normal and do not aid in diagnosis or management. 5

Prognosis and Recovery

Full spontaneous recovery without residual neurological damage is expected with elimination of the medication, even in cases presenting with absent brainstem reflexes. 3, 5, 6

• Recovery typically occurs within 2-3 days of supportive care. 4, 6
• Do not prematurely declare brain death or withdraw care—the prognosis is excellent if recognized early and appropriate supportive measures are instituted. 5, 6

Special Consideration: Intrathecal Baclofen Pumps

For patients with intrathecal baclofen pumps presenting with overdose:

• Check for pump malfunction, catheter problems, or inadvertent bolus administration. 9, 8
• Look for swelling or abnormalities at the pump site during secondary survey. 6
• Diagnosis and repair of pump/catheter malfunction is part of definitive management. 8

Critical Pitfalls to Avoid

• Never assume brain death without considering baclofen overdose in patients with known spasticity or intrathecal pumps. 4, 5, 6
• Never rely on plasma levels to exclude or confirm the diagnosis—this is primarily a clinical diagnosis. 5, 6
• Never withdraw care prematurely based on absent brainstem reflexes—wait 72 hours with full supportive care. 6
• Never delay mechanical ventilation while attempting other interventions. 1