Chapter 176

Toxicity from barbiturates has historically been associated with the highest risk of morbidity and mortality among all sedative-hypnotics.1,2 The therapeutic use of barbiturates has declined due to the introduction of safer, less toxic sedative-hypnotics, such as benzodiazepines, and second-generation anticonvulsants. However, barbiturate overdose and toxicity is still encountered in the ED. During 2008, the American Association of Poison Control Centers noted there were 2719 exposures to barbiturates reported to their centers; 1196 were polydrug exposures that included a barbiturate, 1523 were single drug exposures to a barbiturate, and four deaths were identified.3

Barbiturates are typically used in the treatment of seizure disorders, and for anesthesia induction and procedural sedation.4 They are used in combination drugs, typically butalbital, for the treatment of tension and migraine headaches, although the added efficacy of the barbiturate component is controversial.5,6 Barbiturates are occasionally used as an adjunct for the treatment of acute and chronic pain syndromes.7 Severe ethanol and sedativewithdrawal syndromes are typically managed with benzodiazepines, but barbiturates may have a useful role in combination.8 Barbiturates have been occasionally used in the pharmacologic management of elevated intracranial pressure, although there is little evidence to support this practice.9–11

Barbiturates are generally classified according to their duration of action (Table 176-1). The duration of action depends primarily on their lipid solubility and resulting distribution into the tissues rather than the elimination half-life.

Table 176-1 Selected Properties of Commonly Used Barbiturates

Barbiturates readily distribute throughout the body to most tissues, crossing the blood–brain barrier and placenta and being excreted in breast milk. Fetal blood barbiturate concentrations closely reflect maternal plasma levels, creating the potential for fetal withdrawal syndrome.12 Most barbiturates are metabolized in the liver to inactive metabolites primarily through routes involving ...

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