History

As with any overdose, it is important to attempt to ascertain the exact substance and quantity ingested, the time of ingestion and possible co-intoxicants, especially synergistic toxins such as alcohol or other sedatives. Remember that some barbiturates are included in combination drugs (eg, Fioricet [butalbital, acetaminophen]; Donnatal [phenobarbital, hyoscyamine, scopolamine, atropine]) with components that have their own toxicity profile.

Other important aspects of the history include the following:

Determine if the barbiturate overdose represents a suicide attempt.
Do not overlook the patient's medical history. Most notably, a history of liver disease could potentially result in prolongation of toxic effects.
The depressed mental status patient may harbor intracranial and cervical injury from innocuous trauma.

Physical Examination

A full physical examination is warranted in any overdose. Record vital signs. The patient with barbiturate toxicity may present with any or all of the signs and symptoms listed delow.

Neurologic manifestations may include the following:

Lethargy
Coma
Hypothermia
Decreased pupillary light reflex
Nystagmus
Strabismus
Vertigo
Slurred speech
Ataxia
Decreased deep tendon reflexes

Psychiatric manifestations may include the following:

Impairment in thinking (eg, memory disturbances, poor judgment, limited attention span); delirium of any kind is a cardinal feature
Irritability
Combativeness
Paranoia

Respiratory manifestations may include the following:

Respiratory depression
Apnea
Hypoxia
Acute respiratory distress syndrome

Cardiovascular manifestations may include the following:

Tachycardia
Bradycardia
Hypotension
Diaphoresis
Shock

Other manifestations may include the following:

Severe electrolyte and endocrine disturbances
Renal dysfunction
Gastrointestinal - Decreased bowel sounds
Skin - Barbiturate blisters (ie, bullous lesions typically found on the hands, buttocks, and knees)

Differential Diagnoses

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Media Gallery

Chemical compounds of barbiturates.

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Author

Keith A Lafferty, MD Adjunct Assistant Professor of Emergency Medicine, Temple University School of Medicine; Medical Student Director, Department of Emergency Medicine, Gulf Coast Medical Center

Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Keisha Bonhomme, MD Resident Physician, Department of Internal Medicine, St Vincent’s Medical Center

Disclosure: Nothing to disclose.

Piotr Kopinski Perelman School of Medicine, University of Pennsylvania

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael A Miller, MD Clinical Professor of Emergency Medicine, Medical Toxicologist, Department of Emergency Medicine, Texas A&M Health Sciences Center; CHRISTUS Spohn Emergency Medicine Residency Program

Michael A Miller, MD is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Rehab Abdel-Kariem, MD Resident Physician, Department of Emergency Medicine, Temple University Hospital

Rehab Abdel-Kariem, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians, American Medical Student Association/Foundation, Society for Academic Emergency Medicine, Physicians for Human Rights

Disclosure: Nothing to disclose.