Barbiturate overdose

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Barbiturate overdose
Other namesBarbiturate poisoning, barbiturate toxicity
Phenobarbital2DACS.svg
Molecular diagram of phenobarbital
Specialty Emergency medicine
Symptoms Decreased breathing, decreased level of consciousness [1]
Complications Noncardiogenic pulmonary edema [2]
Duration6–12 hours [2]
CausesAccidental, suicide [3]
Diagnostic method Blood or urine tests [4]
Treatmentmedical support, activated charcoal [5] [6]
FrequencyUncommon [7]

Barbiturate overdose is poisoning due to excessive doses of barbiturates. [8] Symptoms typically include difficulty thinking, poor coordination, decreased level of consciousness, and a decreased effort to breathe (respiratory depression). [1] Complications of overdose can include noncardiogenic pulmonary edema. [2] If death occurs this is typically due to a lack of breathing. [3]

Contents

Barbiturate overdose may occur by accident or purposefully in an attempt to cause death. [3] The toxic effects are additive to those of alcohol and benzodiazepines. [3] The lethal dose varies with a person's tolerance and how the drug is taken. [3] The effects of barbiturates occur via the GABA neurotransmitter. [2] Exposure may be verified by testing the urine or blood. [4]

While once a common cause of overdose, barbiturates are now a rare cause. [7]

Mechanism

Barbiturates increase the time that the chloride pore of the GABAA receptor is opened, thereby increasing the efficacy of GABA. In contrast, benzodiazepines increase the frequency with which the chloride pore is opened, thereby increasing GABA's potency. [9]

Treatment

Treatment involves supporting a person's breathing and blood pressure. [2] [5] While there is no antidote, activated charcoal may be useful. [5] [6] Multiple doses of charcoal may be required. [7] Hemodialysis may occasionally be considered. [6] Urinary alkalinization with sodium bicarbonate may be useful for barbiturate poisoning, targeting a urinary pH greater than 7.5 and ensuring urine output surpasses 2 mL/kg/min. [10]

If a person is drowsy but awake and can swallow and breathe without difficulty, the treatment can be as simple as monitoring the person closely. If the person is not breathing, it may involve mechanical ventilation until the drug has worn off. Psychiatric consult is generally recommended.

Notable cases

People who are known to have died by suicide from barbiturate overdose include Stefan Zweig, [11] [12] Gillian Bennett, [13] Charles Boyer, Ruan Lingyu, Victor Folke Nelson, [14] [15] Dalida, [16] [17] Jeannine "The Singing Nun" Deckers, Felix Hausdorff, Abbie Hoffman, Phyllis Hyman, Marilyn Monroe, Cesare Pavese, C. P. Ramanujam, George Sanders, Carole Landis, Jean Seberg, Lupe Vélez and the members of Heaven's Gate cult. Others who have died as a result of barbiturate overdose include Pier Angeli, Brian Epstein, Judy Garland, Jimi Hendrix, Inger Stevens, Dinah Washington, Ellen Wilkinson, and Alan Wilson; in some cases these have been speculated to be suicides as well. Those who died of a combination of barbiturates and other drugs include Rainer Werner Fassbinder, Dorothy Kilgallen, Malcolm Lowry, Edie Sedgwick and Kenneth Williams. Dorothy Dandridge died of either an overdose or an unrelated embolism. Ingeborg Bachmann may have died of the consequences of barbiturate withdrawal (she was hospitalized with burns, the doctors treating her not being aware of her barbiturate addiction). Maurice Chevalier attempted suicide in March 1971 by swallowing a large amount of barbiturates and slitting his wrists. While he lived, he suffered severe organ damage as a result and died from multiple organ failure nine months later.

Differential diagnosis

The differential diagnosis should include intoxication by other substances with sedative effects, such as benzodiazepines, anticonvulsants (carbamazepine), alcohols (ethanol, ethylene glycol, methanol), opioids, carbon monoxide, sleep aids, and gamma-Hydroxybutyric acid (GHB). Natural disease that can result in disorientation may be in the differential, including hypoglycemia and myxedema coma. In the right setting, hypothermia should be ruled out. [18]

Related Research Articles

<span class="mw-page-title-main">Flunitrazepam</span> Benzodiazepine sedative

Flunitrazepam, sold under the brand name Rohypnol among others, is a benzodiazepine used to treat severe insomnia and assist with anesthesia. As with other hypnotics, flunitrazepam has been advised to be prescribed only for short-term use or by those with chronic insomnia on an occasional basis.

<span class="mw-page-title-main">Hypnotic</span> Drug whose use induces sleep

Hypnotic, or soporific drugs, commonly known as sleeping pills, are a class of psychoactive drugs whose primary function is to induce sleep and to treat insomnia (sleeplessness).

<span class="mw-page-title-main">Diazepam</span> Benzodiazepine sedative

Diazepam, sold under the brand name Valium among others, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, and restless legs syndrome. It may also be used to cause memory loss during certain medical procedures. It can be taken orally, as a suppository inserted into the rectum, intramuscularly, intravenously or used as a nasal spray. When injected intravenously, effects begin in one to five minutes and last up to an hour. When taken by mouth, effects begin after 15 to 60 minutes.

<span class="mw-page-title-main">Lorazepam</span> Benzodiazepine medication

Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting. It is also used during surgery to interfere with memory formation and to sedate those who are being mechanically ventilated. It is also used, along with other treatments, for acute coronary syndrome due to cocaine use. It can be given orally, transdermal, intravenously (IV), or intramuscularly When given by injection, onset of effects is between one and thirty minutes and effects last for up to a day.

<span class="mw-page-title-main">Sedative</span> Drug that reduces excitement without inducing sleep

A sedative or tranquilliser is a substance that induces sedation by reducing irritability or excitement. They are CNS depressants and interact with brain activity causing its deceleration. Various kinds of sedatives can be distinguished, but the majority of them affect the neurotransmitter gamma-aminobutyric acid (GABA). In spite of the fact that each sedative acts in its own way, most produce relaxing effects by increasing GABA activity.

<span class="mw-page-title-main">Drug overdose</span> Use of an excessive amount of a drug

A drug overdose is the ingestion or application of a drug or other substance in quantities much greater than are recommended. Typically it is used for cases when a risk to health will potentially result. An overdose may result in a toxic state or death.

Colloquially known as "downers", depressants or central nervous system (CNS) depressants are drugs that lower neurotransmission levels, decrease the electrical activity of brain cells, or reduce arousal or stimulation in various areas of the brain. Some specific depressants do influence mood, either positively or negatively, but depressants often have no clear impact on mood. In contrast, stimulants, or "uppers", increase mental alertness, making stimulants the opposite drug class from depressants. Antidepressants are defined by their effect on mood, not on general brain activity, so they form an orthogonal category of drugs.

Hypoventilation occurs when ventilation is inadequate to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapnia) and respiratory acidosis. Hypoventilation is not synonymous with respiratory arrest, in which breathing ceases entirely and death occurs within minutes due to hypoxia and leads rapidly into complete anoxia, although both are medical emergencies. Hypoventilation can be considered a precursor to hypoxia and its lethality is attributed to hypoxia with carbon dioxide toxicity.

<span class="mw-page-title-main">Carisoprodol</span> Muscle relaxant medication


Carisoprodol, sold under the brand name Soma among others, is a medication used for musculoskeletal pain. Effects generally begin within half an hour and last for up to six hours. It is taken orally.

<span class="mw-page-title-main">Flumazenil</span> GABA receptor antagonist drug and benzodiazepine antidote

Flumazenil is a selective GABAA receptor antagonist administered via injection, otic insertion, or intranasally. Therapeutically, it acts as both an antagonist and antidote to benzodiazepines, through competitive inhibition.

<span class="mw-page-title-main">Zopiclone</span> Hypnotic medication

Zopiclone, sold under the brand name Imovane among others, is a nonbenzodiazepine used to treat difficulty sleeping. Zopiclone is molecularly distinct from benzodiazepine drugs and is classed as a cyclopyrrolone. However, zopiclone increases the normal transmission of the neurotransmitter gamma-aminobutyric acid (GABA) in the central nervous system, via modulating GABAA receptors similarly to the way benzodiazepine drugs do.

<span class="mw-page-title-main">Eszopiclone</span> Hypnotic medication

Eszopiclone, sold under the brand name Lunesta among others, is a medication used in the treatment of insomnia. Evidence supports slight to moderate benefit up to six months. It is taken by mouth.

<span class="mw-page-title-main">Phenobarbital</span> Medication of the barbiturate type

Phenobarbital, also known as phenobarbitone or phenobarb, sold under the brand name Luminal among others, is a medication of the barbiturate type. It is recommended by the World Health Organization (WHO) for the treatment of certain types of epilepsy in developing countries. In the developed world, it is commonly used to treat seizures in young children, while other medications are generally used in older children and adults. It is also used for veterinary purposes. It may be used intravenously, injected into a muscle, or taken by mouth. The injectable form may be used to treat status epilepticus. Phenobarbital is occasionally used to treat trouble sleeping, anxiety, and drug withdrawal and to help with surgery. It usually begins working within five minutes when used intravenously and half an hour when administered by mouth. Its effects last for between four hours and two days.

Pentobarbital (US) or pentobarbitone is a short-acting barbiturate typically used as a sedative, a preanesthetic, and to control convulsions in emergencies. It can also be used for short-term treatment of insomnia but has been largely replaced by the benzodiazepine family of drugs.

<span class="mw-page-title-main">Butabarbital</span> Chemical compound

Butabarbital is a prescription barbiturate sleep aid and anxiety medication. Butabarbital has a particularly fast onset of effects and short duration of action compared to other barbiturates, which makes it useful for certain applications such as treating severe insomnia, relieving general anxiety and relieving anxiety before surgical procedures; however it is also relatively dangerous particularly when combined with alcohol, and so is now rarely used, although it is still prescribed in some Eastern European and South American countries. Its intermediate duration of action gives butabarbital an abuse potential slightly lower than secobarbital. Butabarbital can be hydrolyzed to valnoctamide.

<span class="mw-page-title-main">Clomethiazole</span> Sedative/Hypnotic medication for alcohol withdrawal

Clomethiazole is a sedative and hypnotic originally developed by Hoffmann-La Roche in the 1930s. The drug is used in treating and preventing symptoms of acute alcohol withdrawal.

<span class="mw-page-title-main">Tricyclic antidepressant overdose</span> Medical condition

Tricyclic antidepressant overdose is poisoning caused by excessive medication of the tricyclic antidepressant (TCA) type. Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest. If symptoms have not occurred within six hours of exposure they are unlikely to occur.

<span class="mw-page-title-main">Benzodiazepine overdose</span> Medical condition

Benzodiazepine overdose describes the ingestion of one of the drugs in the benzodiazepine class in quantities greater than are recommended or generally practiced. The most common symptoms of overdose include central nervous system (CNS) depression, impaired balance, ataxia, and slurred speech. Severe symptoms include coma and respiratory depression. Supportive care is the mainstay of treatment of benzodiazepine overdose. There is an antidote, flumazenil, but its use is controversial.

<span class="mw-page-title-main">Barbiturate</span> Class of depressant drugs derived from barbituric acid

Barbiturates are a class of depressant drugs that are chemically derived from barbituric acid. They are effective when used medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential as well as overdose potential among other possible adverse effects. They have been used recreationally for their anti-anxiety and sedative effects, and are thus controlled in most countries due to the risks associated with such use.

<span class="mw-page-title-main">Salicylate poisoning</span> Medical condition

Salicylate poisoning, also known as aspirin poisoning, is the acute or chronic poisoning with a salicylate such as aspirin. The classic symptoms are ringing in the ears, nausea, abdominal pain, and a fast breathing rate. Early on, these may be subtle, while larger doses may result in fever. Complications can include swelling of the brain or lungs, seizures, low blood sugar, or cardiac arrest.

References

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  2. 1 2 3 4 5 Marx, John A. Marx (2014). "165". Rosen's emergency medicine : concepts and clinical practice (8th ed.). Philadelphia, PA: Elsevier/Saunders. pp. Sedative Hypnotics. ISBN   978-1455706051.
  3. 1 2 3 4 5 Sadock, Benjamin J.; Sadock, Virginia A. (2008). Kaplan & Sadock's Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins. p. 149. ISBN   9780781787468. Archived from the original on 4 November 2016.
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  6. 1 2 3 Roberts, DM; Buckley, NA (January 2011). "Enhanced elimination in acute barbiturate poisoning – a systematic review". Clinical Toxicology. 49 (1): 2–12. doi:10.3109/15563650.2010.550582. PMID   21288146. S2CID   41375480.
  7. 1 2 3 Müller, D; Desel, H (October 2013). "Common causes of poisoning: etiology, diagnosis and treatment". Deutsches Ärzteblatt International. 110 (41): 690–9, quiz 700. doi:10.3238/arztebl.2013.0690. PMC   3813891 . PMID   24194796.
  8. ↑ Dictionary of Medical Terms. Bloomsbury Publishing. 2009. p. 37. ISBN   9781408102091. Archived from the original on 4 November 2016.
  9. ↑ Lafferty, KA; Bonhomme, K; Kopinski, P; Lee, DC; Abdel-Kariem, R (14 January 2017). Tarabar, A; VanDeVoort, JT; Burns, MJ (eds.). "Barbiturate Toxicity: Pathophysiology". eMedicine . New York, USA: WebMD. Archived from the original on 26 August 2017. Retrieved 26 August 2017.
  10. ↑ Singh, Omender; Juneja, Deven (2019). Principles and Practice of Critical Care Toxicology. Jaypee Brothers Medical Publishers Pvt. Limited. ISBN   978-93-5270-674-7. For barbiturate overdose, urinary alkalinization with sodium bicarbonate may be beneficial. The optimum urinary pH which needs to be achieved is >7.5 and urine output should be more than 2 mL/kg/min.
  11. ↑ ""Stefan Zweig, Wife End Lives In Brazil"". New York Times. 23 February 1942. Retrieved 23 February 2012. Stefan Zweig, Wife End Lives In Brazil; Austrian-Born Author Left a Note Saying He Lacked the Strength to Go on – Author and Wife Die in Compact: Zweig and Wife Commit Suicide
  12. ↑ "Died". Time. 2 March 1942. Archived from the original on 14 October 2010. Retrieved 30 June 2010.
  13. ↑ "DeadAtNoon". deadatnoon.com. Retrieved 23 June 2020.
  14. ↑ City of Boston Registry, Certificate of Death record for Victor Folke Nelson, No. 10407, filed 14 December 1939.
  15. ↑ "Dr. Brickley Says Nelson Took Poison." The Boston Globe. 11 December 1939.
  16. ↑ "Dalida". New York Times. 5 May 1987. Archived from the original on 26 May 2012. Retrieved 28 February 2008.
  17. ↑ Simmonds, Jeremy (2008). v. Chicago Review Press. p. 225. ISBN   978-1-55652-754-8. Archived from the original on 18 May 2016.
  18. ↑ Suddock, Jolee T.; Cain, Matthew D. (2020), "Barbiturate Toxicity", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   29763050 , retrieved 5 August 2020
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