Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CASE REPORT
The death of a 43-year-old AfricanAmerican woman was
referred to the Bexar County Medical Examiners Office from a
large community hospital on suspicion of being a zolpidem
overdose case. The initial report received was that the decedent had
taken 60 mg of zolpidem within the 12-hour period before arrival at
the hospital. She died within 15 hours of admission.
The decedent had been brought to the emergency department
by her sister, who described that the decedent was acting strangely
and experiencing visual and auditory hallucinations, none of which
were typical for the decedent. Reportedly, the decedent had told her
sister that she had taken several zolpidem because she could not
sleep. In the emergency room, the patient was disoriented, alert to
person only; however, she was awake and conversant. She denied
taking the medications. The patient stated that she had a history of
bipolar disorder, but did not remember the medications she was
taking. She denied any drug allergies or illicit or intravenous drug
use. Screening laboratory tests were all within normal limits with the
exception of a urine drug screen, which was positive for benzodiazepines. Vital signs showed a markedly elevated blood pressure
(213/125 mm Hg) with 98% oxygen saturation on room air. Her
physical examination was otherwise unremarkable. A head computed tomography scan was negative for any acute abnormality, and
an electrocardiogram showed a rapid sinus rhythm, without ST or T
wave changes. Ultimately, she was diagnosed with acute altered
mental status, most likely secondary to zolpidem overdose and
admitted to the medicine unit.
Upon arrival to the medical floor, the patient continued to
behave bizarrely and presented with a progressive increase in
blood pressure up to 215/150 mm Hg and pulse up to 130 bpm.
Approximately 12 hours after admission, the patient began having
shaking episodes with posturing and an elevated temperature.
She was treated for pseudoseizures with haloperidol, dantrolene, and
phenytoin. She was also given enalapril and labetalol for her
elevated blood pressure; however, the medications had little effect.
In addition, citalopram, piperacillin/tazobactam, ceftriaxone, vancomycin, acyclovir, and vitamin K were administered, most likely in
an attempt to cover for the other causes of acute mental status
changes such as infection or psychosis.
Approximately 14 hours after admission, the patient was
found in her room cyanotic and without respirations. Cardiopulmonary resuscitative measures were performed, but she expired 45
minutes later.
At autopsy, the decedent was an overweight, normally developed woman, 62 inches in length, and weighing 175 lbs (body mass
index, 32.8). She had some minor contusions and abrasions of
www.amjforensicmedicine.com | 177
DISCUSSION
Alprazolam is an intermediate-acting triazolobenzodiazepine
that is FDA-approved for treatment of anxiety and panic disorder. It
has been promoted for its anxiolytic and sedative properties as well
as antidepressant effects. The recommended maximum daily dosage
is 4 mg in divided doses; however, it should be noted that higher
doses ranging 6 to 10 mg/d are often required for effective manage178 | www.amjforensicmedicine.com
Benzodiazepine Withdrawal
www.amjforensicmedicine.com | 179