eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Barbiturate: Follow-up

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

Follow-up

Further Inpatient Care

  • Patients with barbiturate toxicity generally need to be monitored closely and should be in an ICU setting.
  • Hemodialysis and hemoperfusion enhance elimination of barbiturates (this is best established with phenobarbital). Hemoperfusion is more efficacious than hemodialysis but is associated with a higher incidence of complications. Hemodialysis or hemoperfusion may be of benefit for patients resistant to standard supportive care, in stage IV coma, or with shock, severe hypothermia, renal failure, and pulmonary edema. Some recommend extracorporeal removal to shorten the duration of coma when patients are apneic or have serum concentrations of barbiturate >100 mg/L.
  • Barbiturate withdrawal is very similar to ethanol withdrawal. Specifically, one may see a reduction in intoxication and an apparent improvement in condition. This may be quickly followed by anxiety, weakness, tremors, nausea, vomiting, and abdominal cramps. In chronic, heavy users, 1.5-5 days after the last dose the patient may develop seizures, and, between 3 and 7 days after the last dose, delirium tremens may occur. Like ethanol, barbiturate withdrawal may be refractory to benzodiazepine therapy though these medications are first-line therapy.

Complications

  • Overdose with barbiturate may be associated with multiple complications, the most common of which is pneumonia. Other life-threatening complications may include acute renal failure, pulmonary edema, and the sequelae of hypotension and respiratory depression. Survivors may develop dermal bullae.

Prognosis

  • Mortality rates range from 1-10%.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the presence of concomitant intoxicants: Polypharmacy is a key feature of many drug overdoses, and coingestion of CNS depressants exacerbates the effects of a barbiturate overdose. Also, combination drugs may contain acetaminophen, salicylates, and other drugs that may contribute their own significant toxicities.
  • Failure to adequately address and secure an airway
  • Failure to aggressively support blood pressure in hypotensive patients
  • Failure to recognize and treat barbiturate withdrawal in patients at risk
  • Failure to recognize and treat depression in suicidal patients

Special Concerns

  • Pregnancy
    • Barbiturates freely cross the placenta and can have adverse effects on the fetus.
    • Barbiturate exposure is associated with a decrease in fetal intelligence, possible addiction, and possible withdrawal.
    • Overactivity, visible tremors, hypertonicity, hyperphagia, and vasomotor instability characterize neonatal withdrawal syndrome.
    • Withdrawal begins 4-7 days after birth and may last up to 4 months.
    • Support an infant with withdrawal symptoms by decreasing environmental stimulation and by increasing feedings.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Lada Kokan, MD.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Tucker Greene, MD, and Manisha Khatiwala, MD, to the development and writing of this article.



More on Toxicity, Barbiturate

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

References

  1. [Best Evidence] Miner JR, Danahy M, Moch A, et al. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med. Jan 2007;49(1):15-22. [Medline].

  2. Acquaviva R, Campisi A, Murabito P, et al. Propofol attenuates peroxynitrite-mediated DNA damage and apoptosis in cultured astrocytes: an alternative protective mechanism. Anesthesiology. Dec 2004;101(6):1363-71. [Medline].

  3. Barr J, Egan TD, Sandoval NF, et al. Propofol dosing regimens for ICU sedation based upon an integrated pharmacokinetic-pharmacodynamic model. Anesthesiology. Aug 2001;95(2):324-33. [Medline].

  4. Coupey SM. Barbiturates. Pediatr Rev. Aug 1997;18(8):260-4; quiz 265. [Medline].

  5. Feiner JR, Bickler PE, Estrada S, et al. Mild hypothermia, but not propofol, is neuroprotective in organotypic hippocampal cultures. Anesth Analg. Jan 2005;100(1):215-25. [Medline].

  6. Barbiturates. In: Ford: Clinical Toxicology. Chap 68.

  7. Frank LR, Strote J, Hauff SR, et al. Propofol by infusion protocol for ED procedural sedation. Am J Emerg Med. Sep 2006;24(5):599-602. [Medline].

  8. Frazee BW, Park RS, Lowery D, et al. Propofol for deep procedural sedation in the ED. Am J Emerg Med. Mar 2005;23(2):190-5. [Medline].

  9. Frölich MA, Price DD, Robinson ME, et al. The effect of propofol on thermal pain perception. Anesth Analg. Feb 2005;100(2):481-6. [Medline].

  10. Fujii Y, Uemura A. Effect of metoclopramide on pain on injection of propofol. Anaesth Intensive Care. Oct 2004;32(5):653-6. [Medline].

  11. Gary NE, Tresznewsky O. Clinical aspects of drug intoxication: barbiturates and a potpourri of other sedatives, hypnotics, and tranquilizers. Heart Lung. Mar 1983;12(2):122-7. [Medline].

  12. Goldfrank LR, Flomenbau NE. Sedative-hypnotic agents. In: Goldfrank's Toxicologic Emergencies. 5th ed. Prentice Hall; 1994:787-804.

  13. Hadden J, Johnson K, Smith S, et al. Acute barbiturate intoxication. Concepts of management. JAMA. Aug 11 1969;209(6):893-900. [Medline].

  14. Inagawa G, Sato K, Kikuchi T. Chronic ethanol consumption does not affect action of propofol on rat hippocampal acetylcholine release in vivo. Br J Anaesth. 2002;93(5):737-9.

  15. Kanbak M, Saricaoglu F, Avci A, et al. Propofol offers no advantage over isoflurane anesthesia for cerebral protection during cardiopulmonary bypass: a preliminary study of S-100beta protein levels. Can J Anaesth. Aug-Sep 2004;51(7):712-7. [Medline].

  16. Katzung BG. Sedative-hypnotics. In: Basic and Clinical Pharmacology. 6th ed. Appleton & Lange; 1995:333-49.

  17. Khantzian EJ, McKenna GJ. Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med. Mar 1979;90(3):361-72. [Medline].

  18. Lowinson JH, Ruiz P, Millman RB, et al. Epidemiology. In: Substance Abuse: A Comprehensive Textbook. 3rd ed. Lippincott Williams & Wilkins: 1997::10-16.

  19. Lowinson JH, Ruiz P, Millman RB, et al. Sedative hypnotics and tricyclics. In: Substance Abuse: A Comprehensive Textbook. 3rd ed. Lippincott Williams & Wilkins; 1997:223-30.

  20. Motsch J, Toggenbach J. Propofol infusion syndrome. Anaesthesist. 2004;53(10):1023-4.

  21. Nishiyama T, Misawa K, Yokoyama T, et al. Effects of combining midazolam and barbiturate on the response to tracheal intubation: changes in autonomic nervous system. J Clin Anesth. Aug 2002;14(5):344-8. [Medline].

  22. Roberts I. Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev. 2000;CD000033. [Medline].

  23. Romero CE, Baron JD, Knox AP, et al. Barbiturate withdrawal following Internet purchase of Fioricet. Arch Neurol. Jul 2004;61(7):1111-2. [Medline].

  24. Solomon S. Butalbital-containing agents: should they be banned? No. Curr Pain Headache Rep. Apr 2002;6(2):147-50. [Medline].

  25. Subramaniam K, Gowda RM, Jani K, et al. Propofol combined with lorazepam for severe poly substance misuse and withdrawal states in intensive care unit: a case series and review. Emerg Med J. Sep 2004;21(5):632-4. [Medline].

  26. Young WB, Siow HC. Should butalbital-containing analgesics be banned? Yes. Curr Pain Headache Rep. Apr 2002;6(2):151-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

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

[ CLOSE WINDOW ]

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.