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Toxicity, Barbiturate: Differential Diagnoses & Workup

Author: Keith A Lafferty, MD, Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center
Contributor Information and Disclosures

Updated: Oct 1, 2008

Differential Diagnoses

Alcohol and Substance Abuse Evaluation
Toxicity, Benzodiazepine
Depression and Suicide
Toxicity, Carbamazepine
Encephalitis
Toxicity, Carbon Monoxide
Hypoglycemia
Toxicity, Clonidine
Hypothermia
Toxicity, Cyclic Antidepressants
Hypothyroidism and Myxedema Coma
Toxicity, Gamma-Hydroxybutyrate
Pediatrics, Urinary Tract Infections and Pyelonephritis
Toxicity, Neuroleptic Agents
Shock, Cardiogenic
Toxicity, Sedative-Hypnotics
Stroke, Hemorrhagic

Other Problems to Be Considered

Encephalopathy
Head trauma

Workup

Laboratory Studies

  • Obtain a complete blood cell count (CBC), electrolytes, BUN, creatinine, and glucose screen to distinguish barbiturate toxicity from metabolic derangements that can cause similar symptoms.
  • An arterial blood gas (ABG) measurement may help establish the presence and progress of ventilatory failure, hypoxia, and metabolic acidosis.
  • Quantify serum alcohol and barbiturate concentrations (particularly phenobarbital), if possible. Phenobarbital concentrations may be useful to determine the appropriate treatment and, once initiated, efficacy of treatment (eg, urinary alkalinization, multidose charcoal, hemodialysis).
  • A urine drug screen may help establish co-ingestants. Many clinicians routinely obtain acetaminophen and salicylate levels in all overdoses. This is particularly important because barbiturates/combination drugs may contain these analgesics.
  • Blood ethanol concentration may help establish the presence of an important co-ingestant.
  • Be aware of alcohol co-ingestion since a synergistic effect between alcohol and barbiturates may be expected.
  • Obtain a pregnancy test in women of childbearing age.
  • Barbiturate plasma concentrations
    • Barbiturate plasma concentrations aid in diagnosis and help determine whether to institute methods to enhance elimination and whether these methods are effective. They are not accurate for predicting the duration or severity of toxicity.
    • For short-acting barbiturates, a level of 35 mg/L carries an unfavorable prognosis.
    • For long-acting barbiturates, a level of 90 mg/L carries an unfavorable prognosis.
    • These levels do not apply to chronic barbiturate abusers.

Other Tests

  • Electrocardiography
    • In the hypothermic patient, awareness of any rhythm disturbances is important.
    • When the core temperature is below 30ºC (90ºF), risk of ventricular fibrillation is increased.

More on Toxicity, Barbiturate

Overview: Toxicity, Barbiturate
Differential Diagnoses & Workup: Toxicity, Barbiturate
Treatment & Medication: Toxicity, Barbiturate
Follow-up: Toxicity, Barbiturate
Multimedia: Toxicity, Barbiturate
References
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References

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Further Reading

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Keywords

sedative-hypnotic drugs, barbiturate use, barbiturate overdose, barbiturate poisoning, barbiturate toxicity

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Contributor Information and Disclosures

Author

Keith A Lafferty, MD, Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center
Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

David C Lee, MD, Research Director, Department of Emergency Medicine, Assistant Professor, North Shore University Hospital and New York University Medical School
David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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