OBJECTIVE: In the assessment and management of the potentially poisoned patient 
with altered consciousness, the most consequential and controversial 
interventions occur during the first 5 minutes of care. In this review article, 
the risks and benefits of standard diagnostic and therapeutic interventions are 
presented to guide clinicians through this critical period of decision making.
DATA SOURCES: Data for discussion were obtained from a search of 
English-language publications referenced on MEDLINE for the years 1966 to 1994. 
Older literature was included when pertinent. Search terms included poisoning, 
overdose, toxicity, naloxone, glucose, thiamine, and flumazenil.
STUDY SELECTION: Only large trials were used for determinations of diagnostic 
utility and efficacy. Small trials, case series, and case reports were reviewed 
extensively for adverse effects.
DATA EXTRACTION AND SYNTHESIS: Trials were reviewed for overall methodology, 
inclusion and exclusion criteria, sources of bias, and outcome.
CONCLUSION: Analysis favors empirical administration of hypertonic dextrose and 
thiamine hydrochloride to patients with altered consciousness. Although rapid 
reagent test strips can be used to guide this therapy, they are not infallible, 
and they fail to recognize clinical hypoglycemia that may occur without 
numerical hypoglycemia. Administration of naloxone hydrochloride should be 
reserved for patients with signs and symptoms of opioid intoxication. Flumazenil 
is best left for reversal of therapeutic conscious sedation and rare select 
cases of benzodiazepine overdose.