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. A serum lactic acid level may assess cellular hypoperfusion.

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 though its routine use rarely alters treatment and clinical outcome. 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 co-ingestants though its routine use rarely alters treatment and clinical outcome. 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 aid in diagnosis and help determine whether to institute methods to enhance elimination and if so, whether these methods are effective. They are not accurate for predicting the duration or severity of toxicity. Considerations are as follows:

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 long-term barbiturate abusers.

Electrocardiography

Considerations regarding electrocardiography include the following:

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.
Higher toxic doses may induce bradydysrhythmias.

Treatment & Management

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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.