[Attempted suicide with barbiturates purchased online]

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.

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.

Metabolic Correction of Gas Exchange Disturbances in Rats with Barbiturate Coma

Krebs cycle intermediates normalized gas exchange and decreased the mortality rate in rats with barbiturate coma. Treatment with other substrates including glucose and products of glycolysis was ineffective. Oxygen inhalation had no effect on oxygen consumption and indexes of external respiration. Our results suggest that deficiency of endogenous intermediates of the Krebs cycle, but not disturbances in oxygen mass transfer, serves as a limiting factor for oxygen consumption in rats with barbiturate coma.

A suicide by thiopentone infusion

A suicide by intravenous thiopentone infusion is described. A search of the literature revealed only four cases, but this paucity is possibly due to under-reporting, as these suicides occur amongst medical personnel.

A suicide with neuromuscular blocker

We experienced an autopsy case in which a 29-year-old woman committed suicide by parenteral application of a neuromuscular blocker combined with thiobarbital. These medicines were easily accessible to the victim who was an anesthesiologist in a hospital. Paralyzing the respiratory muscles the usual dose of neuromuscular blockers can cause death unless a breathing apparatus is used. Unusual medicines given in small doses are difficult to detect in the autopsy materials. In our case in the course of forensic investigation we successfully identified the traces of a neuromuscular blocker by mass spectrometry.

[Unusual intimal and endocardial damage following suicidal infusion of thiobutabarbital]

A suicide is reported that was carried out by i.v. infusion of thiobutabarbital. The most impressive findings were macroscopical alterations in the venous endothelium, the endocardium of the right atrium and ventricle, and the endothelium of the pulmonary artery. The same local cytotoxic side effects could be reproduced in animal experiments. The lesions are most striking after circulatory stagnation in the agonal and supravital period when highly concentrated thiobarbiturates come into contact with the endothelium.

Thiopental monitoring by gas-chromatography

A gaschromatographic method is presented for the determination of thiopental (and of its metabolite pentobarbital) in cases of severe head injuries treated by induction of therapeutic barbiturate coma. To 1 ml serum the internal standard and saturated ammonium sulphate solution are added. The mixture is extracted by chloroform and the concentrated organic phase is injected into the gaschromatograph (stationary phase: SP 2510 DA). Imprecision from day to day: Coefficient of variation 7.7%; recovery 97%. The specificity was checked by comparison with the retention time of more than 80 drugs. One determination is accomplished within 1 hour.

A suicide by thiopentone injection

Post-mortem tissues from a thiopentone suicide were analysed by ultraviolet spectrometry and gas chromatography. The thiopentone concentrations found (0.6 mg/100 ml of blood and 2 6 mg/100 g of tissue) are consistent with those reported for 'anaesthetic' deaths where only thiopentone and other anaesthetic agents were present. The gas chromatographic method gave more accurate result with the tissues.

Criminal poisoning with anaesthetic drugs: murder, manslaughter, or not guilty

Criminal poisoning is uncommon and the use of anaesthetic and related drugs for this purpose is very rare. Seven cases, involving the use of morphine, chloroform, hyoscine, thiopental, and succinylcholine, are described. In three cases the accused was found guilty of murder, in two guilty of manslaughter, in two not guilty and in one the verdict is not known.

Thiopental suicide -- case report

Thiopental was indicated in the suicide death of a hospital employee. The blood thiopental level was determined to be 27.9 mg% by ultraviolet spectrophotometry, and positive identification was accomplished using gas chromatography, thin-layer chromatography, and infrared spectrophotometry.