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Coma cocktail: a role for flumazenil?

A common clinical scenario in the emergency department is a patient with a presumed drug overdose. Patients are often unresponsive with respiratory depression and hence unable to give a clear history. When the culprit toxin is known, rapid reversal with administration of the relevant antidote may be life saving. The empirical administration of a ‘coma cocktail’ consisting of naloxone, glucose and thiamine is common in many emergency departments. It is tempting to add flumazenil to this cocktail if there is a suspicion of benzodiazepine misuse; however, the possibility of mixed overdose or any suggestion of long-term benzodiazepine use should influence management choices.