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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
- Epileptic seizure
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Diffuse brain dysfunction
Primary CNS disease or trauma
Psychiatric
Evaluation
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
See Also
External Links
References
