[Attempted suicide with barbiturates purchased online]. / Tentamen suicidii met barbituraten van internet.

BACKGROUND: Barbiturate intoxication is potentially lethal. With the availability of the newer anticonvulsants the use of barbiturates in treating epilepsy has decreased significantly, with a concurrent decrease in the incidence of overdose with these medications. There have, however, been recent alarm signals from governmental sources concerning the increase in the Internet purchase of illegal medications, including barbiturates, for use in attempted suicide. CASE DESCRIPTION: Here we describe two patient cases involving barbiturate intoxication with amobarbital and thiopental, respectively. They had both obtained the barbiturates via the Internet. Both patients were comatose and showed signs of respiratory depression; one of them was also haemodynamically unstable. Both patients recovered fully following intensive supportive therapy. CONCLUSION: In patients with coma, respiratory depression, absence of brainstem reflexes and shock with no evident cause one should be aware of the possibility of barbiturate intoxication, even when there is no indication that these have been prescribed or that the patient has direct or indirect access to barbiturates. Prompt, optimal supportive therapy will give a good chance of full somatic recovery.

A study of the risk of mental retardation among children of pregnant women who have attempted suicide by means of a drug overdose.

BACKGROUND: The aim of the study was to estimate the effect on the fetal development of high doses of prescription drugs taken as a suicide attempt during pregnancy. METHODS: Pregnant women were identified among self-poisoned females in the toxicological inpatient clinic in Budapest between 1960 and 1993. Congenital abnormalities, intrauterine development based on birth weight and post-conceptional age, mental retardation, cognitive-behavioral status were compared in exposed children born to mothers who had attempted suicide by means of a drug overdose during pregnancy with their siblings, born either before or after the affected pregnancy, as sib controls. RESULTS: Of a total of 1 044 pregnant women, 74 used the combination of amobarbital, glutethimide and promethazine (Tardyl®, one of the most popular drugs for treatment of insomnia in Hungary) for suicide attempt. Of these 74 women, 27 delivered live-born babies. The mean dose of Tardyl® used for suicide attempts was 24 times the usually prescribed clinical dose. The rate of congenital abnormalities and intrauterine retardation was not higher in exposed children than in their sib controls. However, of the 27 exposed children, eight (29.6%) were mentally retarded (X²1=79.7, p= Sig) while mental retardation did not occur among 46 sib controls. These exposed children were born to mothers who attempted suicide with Tardyl® between the 14th and 20th post-conceptional weeks. The components of Tardyl® used separately for a suicide attempt during pregnancy were not associated with a higher risk of mental retardation. Therefore the high doses of Tardyl® associated with the high risk for mental retardation may be due to the interaction of its three drug components. CONCLUSIONS: The findings of the study showed that the high doses of a drug containing three components may be associated with a significantly increased risk for mental retardation without any structural defects, whereas each of these three component drugs taken alone was not associated with this adverse effect.

A study of the teratogenic and fetotoxic effects of large doses of amobarbital used for a suicide attempt by 14 pregnant women.

The teratogenic effect of barbitals is debated, and this study was performed to identify the effects of very large doses of amobarbital used for suicide attempts during pregnancy on embryo-fetal development. Self-poisoned pregnant women were identified from patients of the Department of Toxicology Internal Medicine, Korányi Hospital, Budapest, Hungary, who were admitted from the 3 million people of Budapest and its surrounding region. A comparison was made between outcomes of pregnancies of women who attempted suicide with amobarbital alone or in combination with other drugs during pregnancy with sib controls. Of 1044 women with self-poisoning during pregnancy between 1960 and 1993, 33 used amobarbital for a suicide attempt. Of these 33 women, 14 delivered live-born babies. The dose of amobarbital taken by these women ranged between 600 and 10,000 mg, with a mean of 3886 mg. Of the 14 amobarbital-exposed children, 9 had mothers who attempted suicide between the 3rd and 12th post-conceptional weeks. None of these children had a congenital abnormality, and there was no evidence of fetal growth retardation. The distribution of cognitive status and behavioral scale of the exposed children were comparable with those of their sibs although one exposed child had a very low (about 75) IQ, whereas another one was treated because of a very severe aggressive behavioral deviation. Exposure to very large doses of amobarbital that were used for self-poisoning during pregnancy did not produce teratogenic effects in this study.

Intermediates of Krebs cycle correct the depression of the whole body oxygen consumption and lethal cooling in barbiturate poisoning in rat.

Rats poisoned with one LD50 of thiopental or amytal are shown to increase oxygen consumption when intraperitoneally given sucinate, malate, citrate, alpha-ketoglutarate, dimethylsuccinate or glutamate (the Krebs cycle intermediates or their precursors) but not when given glucose, pyruvate, acetate, benzoate or nicotinate (energy substrates of other metabolic stages etc). Survival was increased with succinate or malate from control groups, which ranged from 30-83% to 87-100%. These effects were unrelated to respiratory depression or hypoxia as judged by little or no effect of succinate on ventilation indices and by the lack of effect of oxygen administration. Body cooling of comatose rats at ambient temperature approximately 19 degrees C became slower with succinate, the rate of cooling correlated well with oxygen consumption decrease. Succinate had no potency to modify oxygen consumption and body temperature in intact rats. A condition for antidote effect of the Krebs intermediate was sufficiently high dosage (5 mmol/kg), further dose increase made no odds. Repeated dosing of succinate had more marked protective effect, than a single one, to oxygen consumption and tended to promote the attenuation of lethal effect of barbiturates. These data suggest that suppression of whole body oxygen consumption with barbiturate overdose could be an important contributor to both body cooling and mortality. Intermediates of Krebs cycle, not only succinate, may have a pronounced therapeutic effect under the proper treatment regimen. Availability of Krebs cycle intermediates may be a limiting factor for the whole body oxygen consumption in barbiturate coma, its role in brain needs further elucidation.

[Suicidal attempts with old (currently unused) drug]. / Zatrucie samobójcze lekiem z przeszlosci.

Suicidal attempt with old (currently unused) drug is described. The suicidal attempts are usually performed with the use of contemporary pharmacotherapeutics. In the report a case of suicidal attempt with old drug Tardyl is presented. Tardyl (Glutethimid) was prescribed to the patient and has been stored for 20 years. The patient was previously treated for depression and many suicidal attempts. In the course of intoxication: balance disturbances, psychomotor retardation, changes in consciousness with temporary excitation were observed. The concentration of glutethimid in the urine was 1.1 mg% and 0.5 mg% in the blood. Patient was treated according to the general rules of intensive care. After 4 days of therapy the patient improved and was transferred to psychiatric unit in Koscian.

Toxicological analysis of amobarbital and glutethimide from bone tissue.

Author examined cadaver organs and bone samples (sternum, rib) of drug poisoning cases. Following suitable procedures, active drug components (amobarbital, glutethimide, and so forth) were identified by gas chromatography/mass spectrometry (GC/MS). Based on results of quantitative GC analysis, relationships were sought between the active agent concentrations measured in the organs and the bone samples.

Nonaccidental poisoning: the elusive diagnosis.

Although nonaccidental poisoning in childhood is now more often recognised, it is still difficult to establish a diagnosis despite correct investigative procedures. In 1978 we were unable, initially, to establish the cause of intermittent episodes of loss of consciousness in a boy admitted to Sheffield Children's Hospital. Subsequently it was conclusively shown that his mother systematically poisoned him with Tuinal (amylobarbitone and quinalbarbitone) both before admission and while he was being treated in the hospital.

Suicide by intravenous injection of a veterinary euthanasia agent: report of a case and toxicologic studies.

Previously reported cases of suicide by intravenous barbiturates, as well as two other unusual cases [5,6], are compared in Table 2. All decedents were either medical or paramedical personnel and familiar with the drugs and the routes of administration used for their suicides. Lethal is used in veterinary euthanasia at an intravenous dose of 1 ml per 5 kg (10 lbs) body weight. Unconsciousness usually occurs during injection and death supervenes within a matter of seconds. The decedent in the present case weighed 90 kg (200 lbs) and had injected at least 40 ml of the drug, approximately twice the recommended lethal dose. There appears to be little doubt of the victim's suicidal intent, since he had used Lethal in his daily occupational duties. Additionally, the physical configuration of the supports devised to hold the syringe was quite stable, and injection stopped only when the decedent's hand came to rest upon the towels. To our knowledge, the present case represents the only one of its kind in the literature.

Clinical and metabolic features of overdosage with Amesec.

A 23-year-old woman ingested 2g. amylobarbitone, 10.4g. aminophylline and 2g. ephedrine. She was deeply unconscious, hypothermic, and went on to have supraventricular and ventricular dysrhythmias, convulsions and haematemesis. During the last convulsion she aspirated vomitus and died. The peak plasma concentration of amylobarbitone was 19mg. per l. and those of ephedrine and theophylline were 13 times higher than accepted therapeutic levels. During the course of the poisoning marked hypokalaemia (1.8mmol./l.) and hyperinsulinaemia (greater than 240mU./l.) were found in conjunction with mild hyperglycaemia (9.6mmol./l.) and elevation of free fatty acid levels (1860mumol./l.). The mechanism of these changes is discussed.

[Demonstration of hypnotic agents in bone tissue]. / Altatószerkimutatás csontszövetböl.

Investigating the skeletons of 25 suicide victims the authors have found that the toxic materials taken can rather comfortably and safely be detected in the compactbony substance. Especially important that the poisonous drug residues can remain in the bones for a long time, even for years after death.

Accidental poisoning with psychotropic drugs in children.

Seventy-seven (0.24%) of 32,005 admissions to the Massachusetts General Hospital pediatric service during the period 1962 to 1973 were due to accidental poisoning. In 27 cases, mostly involving children less than 6 years of age, psychotropic drugs were implicated. These included sedative-hypnotics in six cases, phenytoin in two, major tranquilizers in five, antidepressants in three, stimulants or hallucinogens in three, and drug mixtures in eight. Toxicologic analyses contributed little to diagnosis and initial management. Except for one child who ingested ferrous sulfate, no patient was seriously intoxicated, and all recovered rapidly without sequelae. Although referral of serious poisoning cases to another hospital may have biased the results, the findings suggest that accidental psychotropic drug poisoning is not a major source of childhood morbidity.

Transcutaneous aortovelography. Potentially useful technique in management of critically ill patients.

Pilot evaluation of the clinical use of transcutaneous aortovelography has been undertaken and suggests that this technique will be useful in the assessment of left ventricular function in the acutely ill patient. Changes in waveform as a result of therapy or alteration in clinical condition can frequently be noted by critical visual assessment. Increasing clinical experience suggests that quantification will permit interpretation of less obvious changes in the recorded waveform. Transcutaneous aortovelography has the simplicity, speed, and safety afforded by a non-invasive technique.

Resin hemoperfusion for acute drug intoxication.

Eight patients with drug intoxication were hemoperfused on ten occasions at a blood-flow rate of 300 ml/min with a 650gm column of Amberlite XAD-4 resin, which is a macroreticular resin with a specific adsorptive attraction for lipid-soluble organic molecules. Column clearances of glutethimide and a variety of barbiturates ranged from 207 to 300 ml/min for treatment sessions extending from 2 1/2 to ten hours. After ingestion of 75 gm of glutethimide, one patient received hemoperfusion on three successive days for nine, ten, and eight hours, respectively. She recovered after the column removed over 30 gm of drug. The patients demonstrated dramatic clinical responses with no evidence of meaningful toxic reactions. Column hemoperfusion with Amberlite XAD-4 resin was simpler and more effective than any known method of removing barbiturates and glutethimide from the blood of patients with drug overdoses.

Studies with activated charcoal in the treatment of drug overdosage using the pig as an animal model.

Pigs were given large oral doses of paracetamol, amylobarbitone and amitriptyline. The effect of administering activated charcoal at varying intervals after dosing on the blood drug-level profiles of paracetamol and amylobarbitone was assessed by comparison with the profiles obtained when charcoal therapy was withheld. An appreciable effect on paracetamol absorption was demonstrated when charcoal was given up to 1 h after dosing. The amylobarbitone-dosed pigs exhibited delayed gastro-intestinal absorption of drug and this was substantially reduced by activated charcoal given 4 hrs after dosing. The pigs metabolised amitriptyline at too high a rate for meaningful studies to be undertaken with this drug.