Ann Arens1,2, Craig Smollin1!!

1. California Poison Control System, San Francisco Division, UCSF 2. Veterans Affairs Medical Center, San Francisco!!!

Introduction:!•  Pentobarbital is a long acting barbiturate

(t ½ 4-50 hours)!•  FDA approved uses: Anesthesia adjunct,

Insomnia, Sedation, Seizure!•  No longer available as an oral formulation in

the United States!!

•  Capital Punishment!•  2010 EU banned exportation of thiopental

sodium to US!•  March 10, 2011

Ohio becomes first state to use pentobarbital-only euthanasia!

!

•  Exit International !•  Australian organization established in 1997 !

•  Promotes a “non-medical approach to a person’s right to determine the time and manner of their passing.”!!!

•  The Peaceful Pill Handbook !•  Pentobarbital “Nembutal’ supported

as an option for suicide !!

!

Case discussion!We report a case of a patient who suffered a cardiac arrest and prolonged coma following an intentional Pentobarbital overdose confirmed on laboratory analysis. !•  The initial arrest was likely the result of

respiratory arrest. !•  The patient recovered without neurologic

sequelae after supportive care alone.! !

!Conclusions:!!Overdose of Pentobarbital is rare given oral Pentobarbital is no longer prescribed in the United States, however, Pentobarbital may still be purchased online. !•  Pentobarbital overdose may results in

cardiopulmonary arrest and prolonged coma. !!!!!!!!

References:!1.  Brandt-Casadevall C, Krompecher T, Giroud C, Mangin P. A case of

suicide disguised as natural death. Sci Justice. 2003 Jan-Mar;43(1):41-3.!2.  Giroud C, Augsburger M, Horisberger B, Lucchini P, Rivier L, Mangin P.

Exit association-mediated suicide: toxicologic and forensic aspects.Am J Forensic Med Pathol. 1999 Mar;20(1):40-4.!

3.  Fell RH, Gunning AJ, Bardhan KD, Triger DR. Severe hypothermia as a result of barbiturate overdose complicated by cardiac arrest.Lancet. 1968 Feb 24;1(7539):392-4. !

4.  Dyer O.The slow death of lethal injection. BMJ. 2014 Apr 29;348:g2670.!

Case Report!Pre-Hospital Course!•  61-year-old male was brought in by ambulance

after an unwitnessed cardiac arrest.!

•  Patient was found down in a hotel room pulseless and apneic after last being seen normal 12 hours prior!

•  On EMS arrival:!•  Patient was intubated!•  The patient was defibrillated once, followed by

2 rounds of epinephrine and CPR with return of spontaneous circulation (ROSC)!

!ED Course!VS: BP 107/94, HR 89 (irreg), RR 14, 97% BVM, 27.5°C !

•  Neuro: GCS 3, Pupils dilated and non reactive No rectal tone!

•  Additional V. Fib arrest in the ED Defibrillation x 3 at 200J to achieve ROSC !!•  Epinephrine drip for pressor support!

•  Cooling protocol to maintain hypothermia!

Initial Labs:!

! !

!!

!

!!!!

Cardiac Arrest After Intentional Pentobarbital Overdose

Course Continued!

Family arrives and explains the patient recently acquired Pentobarbital online and had expressed suicidal ideation the day prior to arrival.!

!The patient may have taken up to 5 grams!

143! 111! 18!7!

184!3.4! 25! 1.0!

Hospital Day!

Clinical Status! Interventions!

#1! Persistent lactic acidosis!Hypotension!

Cooling maintained!Epinephrine for pressor support!

#3! Cardiac arrhythmias!Hypokalemia!

Rewarming initiated!!

Pentobarbital level: 22.4 mcg/mL!

#6! Off pressors !!

MRI brain normal !!

Pentobarbital level: 6.1 mcg/mL!

#8! Patient Extubated!

Placed on BiPaP, weaned successfully!

#9 - 24! R sided empyema!

Placed on BiPaP!Pleural drain placed (removed HD #25)!

# 25! Patient discharged home without neurologic sequela!

Lactate: 1.8!APAP: < 2.0 μg/mL!ASA: < 10 μg/dL!EtOH < 10!Urine Tox: +Barbiturates, +THC!Phenobarbital: 2.9 μg/mL!

Pentobarbial Reference Levels!Pentobarbital level (mcg/mL)! Therapeutic Effect!

1.0 – 5.0 ! Hypnotic!

30.0 – 40.0! Reduction of Intracranial Pressure!

20.0 – 50.0! Therapeutic Coma!