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Barbiturate withdrawal
From WikEM
Contents
Background
- Presentation similar to alcohol withdrawal
- Tolerance and dependence on barbiturates develops rapidly
Clinical Features
- Onset of minor symptoms within 24h of abrupt cessation
- Major, life-threatening symptoms occur ~2-8 days after stopping drug
- Symptoms more severe with higher dose, longer duration of use, and use of short-acting barbiturates
- Autonomic hyperactivity (e.g., diaphoresis, HR>100, hyperthermia)
- Nausea/vomiting, abdominal cramping
- Tremulousness, psychomotor agitation, muscle twitching
- Anxiety, insomnia, irritability agitation
- Psychosis (more common than in ETOH withdrawal)
- Seizure
Differential Diagnosis
Sedative/hypnotic withdrawal
- Toxic alcohols
- Ethanol
- Ethylene glycol
- Methanol
- Isopropyl alcohol
- Benzodiazepines
- Flunitrazepam (Rohypnol)
- Gamma hydroxybutyrate (GHB)
- Barbiturates
- Opioids
- Chloral hydrate
Seizure
- Epileptic seizure
- Non-epileptic seizure
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacture Combined Degeneragion (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- Intraparenchymal hemorrhage
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic Encephalitis]
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
- Acute psychosis
- Excited delirium
- Malingering
Evaluation
- Evaluate for other causes of and complications of symptoms (see evaluation of seizure, altered mental status, hypertension, hyperthermia
Management
- Ensure patient and staff safety, airway protection if acutely agitated or seizing
- Seizures can be treated with benzodiazepines, but management with barbiturates (e.g. phenobarbital) generally more effective
- Generally need gradual detox as inpatient
Disposition
- Admit for gradual detoxification
