Deliberate self-poisoning with a lethal dose of pentobarbital: Survival with supportive care. Santosh Gone(1), Andis Graudins(1,2) (1) Clinical Toxicology Service, Program of Emergency Medicine, Monash Health

(2) Monash Emergency Research Collaboration, Clinical Sciences at Monash Health, Monash University Abstract 84

INTRODUCTION CASE REPORT (continued) DISCUSSION Pentobarbital (Nembutal) is short acting In the ED: Pentobarbital has been a banned substance for barbiturate sedative-hypnotic, currently widely GCS: 3/15, fixed dilated pupils, apnoeic and human use in Australia since 1998. However, it can used in veterinary practice for anesthesia and ventilated. be procured overseas or bought on the internet. euthanasia. Pulse: 116 bpm sinus tachycardia BP: 115/60 on epinephrine infusion. Pentobarbital is recommended as an effective It is also commonly recommended as a VBG: pH 7.03 pCO2 77 mmHg Bicarb 19 mmol/L agent for use in euthanasia due to its apparently euthanasia drug for assisted suicide and it is Lactate 8.8 mmol/L peaceful transition to death. unlikely that any resuscitative measures will be Activated charcoal (50g) given via an NG tube. attempted in such cases. Course in the Intensive Care Department: In a case series of 150 assisted suicides in Day-1 post-OD: Sweden, a 100% success rate was seen with Intentional overdose results in depression of - Absent brain stem reflexes and fixed dilated pupils for ingestion of 9 grams. Cardiovascular collapse was brain stem function and rapid onset respiratory five days. seen within 15 minutes in 30% of patients. It is rare depression and apnoea. Hypotension also - Diabetes insipidus developed with urine output of to see survival after intentional ingestion for develops, followed by cardiovascular collapse 300ml/hour. Treated with desmospressin. assisted suicide and CPR is rarely, if ever, and death. Day-3 post-OD: performed in these cases. - Four-vessel CT angiogram showing normal perfusion. We report a case of survival following Day-5 post-OD: This case is unique, in that the patient called for deliberate self-poisoning with a potentially - Return of gag reflex on suctioning and eye opening. help early, CPR was commenced rapidly, and lethal dose of pentobarbitone where timely BLS Vasopressor requirement reducing and norepinephrine supportive care continued until the patient and ALS life-support was commenced at the ceased on day-5. recovered. scene and ongoing supportive care in the Day-7 post-OD: intensive care department (ICU) resulted in a - Sedation with propofol commenced Hemodialysis was not commenced in this patient favourable outcome. - Responding to painful stimuli based upon lack of evidence for effectiveness in Day-9 post-OD: short-acting barbiturate poisoning. - Obeying simple commands, eye opening to voice and recognizing family. Extubation delayed due to aspiration Charcoal hemoperfusion has been reported to CASE REPORT pneumonitis. enhance pentobarbital elimination and improve - A 41-year-old male was brought into the Day 11 post-OD: survival in animal models. However, we did not Emergency Department (ED) after Nembutal - Discharged to medical ward. Neurologically intact. have access to this modality. overdose (pentobarbital) 25 grams. He had - Treatment for aspiration pneumonitis and physiotherapy purchased the drug over the internet two-years to improve strength and mobility. Retrospectively analysed serial blood assays of earlier. The dose ingested was confirmed on Day 22 post-OD: Mental health admission. pentobarbital revealed peak concentration day-2 extubation. post-OD suggesting ongoing absorption despite a Background: single dose of activated charcoal and potentially - The patient suffered from major depression and PENTOBARBITONE SERUM DRUG lethal serum concentrations (>24mg/L) for five days had a recent discharge from a private mental ASSAY post-ingestion. Neurologic responsiveness correlated with a fall in serum concentration below health facility following ECT. Serial serum pentobarbital concentrations were assayed by quantitative high - The patient reported thoughts of self-harm for performance liquid chromatography / mass spectrometry. 24 mg/L). several weeks prior to presentation. At home: 120 Early by-stander CPR and advanced life- - On the day of presentation, the patient took an 110 support with ongoing respiratory and impulsive overdose of 25 grams of pentobarbital. 100 cardiovascular supportive care in the ICU resulted in complete recovery in this patient. - He immediately phoned his mother, who called 90 for an ambulance and rushed to his assistance. 80

- Ten minutes post-OD she found him 70 unresponsive and started CPR. 60

- On paramedic arrival 20 minutes post-OD, he 50 was comatose and pulseless. 40

- The patient was intubated and advance life- (mg/L) Pentobarbitone 30 support commenced, including 3 doses of Reported lethal > 24 REFERENCES 20 epinephrine (1mg each) and a crystalloid fluid 1.Singh V. Survival after fatal pentobarbital ingestion. Hypnotic < 10 Indian Journal of Anaesthesia. 2014;58(1):85-86. bolus. 2. Bironneau E, et al. Hemodiafiltration in pentobarbital poisoning. 0 Ren Fail. 1996;18(2):299–303. - Circulation was re-established after 15 minutes. 0 20 40 60 80 100 120 140 160 180 200 220 3. Mactier R, et al. Extracorporeal Treatment for Barbiturate Poisoning-- - An epinephrine infusion (100mcg/min) was Time post-ingestion (hrs) Recommendations From the EXTRIP Work Group Am J Kidney Dis. 2014; 64(3): 347-358. commenced for ongoing hypotension during 4. Hill, JB, et al. Efficacy of activated charcoal hemoperfusion in removing lethal doses of barbiturates and salicylate from the blood of transport to the ED. rats and dogs. Clin Chem. 1976; 22(6): 754-760. - No other drugs or alcohol were ingested. Return of gag Sedation with Obeying reflex profol commands Eye opening commenced Eyes open to with suction Responds to voice pain Recognizes family