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Barbiturate overdose

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Barbiturate overdose
Other namesBarbiturate poisoning, barbiturate toxicity
Molecular diagram of phenobarbital
SpecialtyEmergency medicine
SymptomsDecreased breathing, decreased level of consciousness[1]
ComplicationsNoncardiogenic pulmonary edema[2]
Duration6–12 hours[2]
CausesAccidental, suicide[3]
Diagnostic methodBlood 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]

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

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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

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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

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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 the 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

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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]

References

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  1. ^ a b Weaver, MF (3 September 2015). "Prescription Sedative Misuse and Abuse". The Yale Journal of Biology and Medicine. 88 (3): 247–56. PMC 4553644. PMID 26339207.
  2. ^ a b c d e 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. ^ a b c d e 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.
  4. ^ a b Baren, Jill M. (2008). Pediatric Emergency Medicine. Elsevier Health Sciences. p. 955. ISBN 978-1416000877. Archived from the original on 4 November 2016.
  5. ^ a b c Carroll, Robert G. (2010). Problem-based Physiology. Elsevier Health Sciences. p. 99. ISBN 978-1416042174. Archived from the original on 4 November 2016.
  6. ^ a b c 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. ^ a b c 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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