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use or drug trade (which is most common in adolescents), but, commonly, exposure is initiated through a physician’s prescription to a parent for insomnia or anxiety The sedative-hypnotics reversibly depress the activity of all excitable tissues For most of these agents, CNS effects occur with little action on skeletal, cardiac, or smooth muscle Uncommonly, serious depression in cardiovascular and other functions may occur The pharmacologic characteristics of each drug are largely determined by their specific chemical nature For example, all barbiturates are bound by plasma proteins These characteristics have important implications in affecting their renal elimination and the effectiveness of extracorporeal drug removal techniques (hemodialysis, hemoperfusion) Because tolerance develops to most of the actions of these drugs, no signs of chronic use may be apparent Clinical Considerations After sedative-hypnotic use, the adolescent may exhibit sluggishness, difficulty in thinking, dysarthria, poor memory, faulty judgment, emotional lability, and short attention span The classic presentation of oral sedative-hypnotic overdose is lethargy or coma with relatively normal vital signs Respiratory depression may be seen, especially with combination sedative-hypnotic ingestions (i.e., benzodiazepines and ethanol) Toddlers who unintentionally ingest benzodiazepines may present with acute ataxia With chronic use, these drugs also lead to dependence, so a picture of abstinence may appear after their disuse, with clinical manifestations of apathy, weakness, tremulousness, agitation, or convulsions In its mildest form, the abstinence syndrome may consist only of rebound increases of rapid eye movement sleep, insomnia, or anxiety Direct initial attention to ensuring a patent airway and assessing an intact gag reflex Monitor end-tidal CO2 , if available, to detect worsening ventilation Cardiovascular disturbances are rare after sedative use, but because of the possibility of drug coingestion, thorough hemodynamic assessment is necessary Many sedative-hypnotics are detectable on comprehensive toxin screens, so specimens of serum and urine may be sent for analysis; however, these screens rarely come back in real time, thus minimizing their importance at the bedside GI decontamination should be considered in select cases and can typically be confined to administration of activated charcoal Repeated doses of charcoal enhance clearance of certain barbiturates and benzodiazepines Urinary alkalinization aids in the excretion of phenobarbital In extreme cases, consider charcoal hemoperfusion, but most patients will recover with supportive care
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