Acute barbiturate poisoning: symptoms, treatment

Poisoning and overdose with various medications are not uncommon. At the same time, one of the most unfavorable intoxications is considered to be poisoning with barbiturates - derivatives of barbituric acid, which inhibits the function of the central nervous system. Ten years ago, barbiturates were widely used in medicine: they were used as drugs that accelerate sleep, calm and relieve convulsions. However, in recent years, their popularity has significantly decreased - primarily due to their property of causing addiction of the body.

Barbiturates – what are they?

Barbiturates are drugs produced on the basis of barbituric acid. However, this acid itself does not have a hypnotic effect. Over the entire period of use, about a hundred barbiturate drugs have been artificially isolated, but doctors officially use only about thirty options.

Barbiturates are whitish or yellowish crystals with poor water solubility and good fat solubility. Sodium salt of barbiturates, on the contrary, dissolves better in water.

Barbiturates are well absorbed in the digestive organs by passive transport, and this reaction is enhanced by ethyl alcohol. The maximum plasma concentration is:

• barbital – from 4 to 8 hours;
• phenobarbital – from 12 to 18 hours.

Barbiturates actively interfere with the functioning of the central nervous system and, depending on the dose, have the following effects:

• weakly calming;
• speed up falling asleep;
• relieve pain;
• eliminate cramps.

Absolutely all barbiturate drugs are capable of depressing the central nervous system. In small quantities, they can provoke a euphoric state, reminiscent of mild intoxication: coordination deteriorates, gait and speech are impaired, control over behavior and emotional manifestations is lost.

To achieve a calming effect and facilitate sleep, it is necessary to take a slightly larger dose of barbiturate, and the highest doses are already used as means for surgical anesthesia.

[ 1 ], [ 2 ]

List of drugs - barbiturates

Barbiturates are divided into the following types: drugs with ultra-short action, with medium-term and long-term effect.

Barbiturates, which are currently widely used in surgical anesthesia, have an ultra-short effect. These drugs include Methohexital, Thiopental, and Thiamylal.

Talbutal, Pentobarbital, Butalbital have a medium-term effect. The effect of such barbiturates is noted already 15-35 minutes after administration, and lasts for about six hours.

A typical representative of a barbiturate with a long-lasting effect is Phenobarbital - it is used primarily to treat patients with epilepsy.

The basic representatives of barbiturates are the following medications:

• Amobarbital (fatal poisoning occurs when 2-4 g of the drug is consumed);
• Cyclobarbital (fatal poisoning occurs when taking 5-20 g of the drug);
• Barbital (death occurs after taking 6-8 g of the drug);
• Phenobarbital (death from poisoning occurs after taking 4-6 g of the drug);
• Heptabarbital (fatal poisoning occurs after consuming 20 g of the drug);
• Diethylbarbituric acid (fatal outcome observed after consuming 6-8 g of the drug).

Epidemiology

Barbiturate poisoning occurs in approximately 20-25% of patients treated in specialized toxicology clinics; they also account for approximately 3% of all fatal intoxications. The general hospital mortality rate for barbiturate poisoning averages 2%, taking into account cases of combined intoxication with different medications that have a psychotropic effect.

If barbiturate poisoning is severe and the patient falls into a coma, the mortality rate increases to 15%.

Today, barbiturates are practically not used as sleeping pills and sedatives: they are used as an anesthetic, or to relieve convulsive states or prevent epileptic seizures.

[ 3 ], [ 4 ]

Causes barbiturate poisoning

Barbiturate poisoning most often occurs intentionally - for example, for the purpose of committing suicide or murder, or through accidental ingestion of a large dose of the drug.

Barbiturates taken orally are absorbed by the walls of the small intestine. After entering the bloodstream, they bind to plasma proteins and are metabolized in the liver. A quarter of the total amount of barbiturates taken is excreted unchanged in the urine: this point is actively used in the diagnosis of poisoning.

In general, barbiturates are taken by patients to improve sleep, to calm down, as sleeping pills and sedatives. Poisoning can occur with accidental use of a large amount of medication: and this is not uncommon, since barbiturates cause gradual addiction of the body, a person begins to take larger and larger doses. The most common cause of death is the development of respiratory and liver failure, shock process and cardiac arrest.

[ 5 ], [ 6 ]

Risk factors

Most often, barbiturate poisoning is recorded in the following people:

• in those who take barbiturates as prescribed by a doctor, but for a long time;
• in those who combine the use of barbiturates with alcohol consumption;
• in those who take such medications on their own, chaotically and in arbitrary dosages;
• in those who use barbiturates for other purposes (for example, to achieve a euphoric state).

Thus, the risk group may include patients with neurotic disorders, impaired social adaptation, as well as individuals who abuse alcohol.

Barbiturates eliminate insomnia, ease affective states, relieve anxiety and improve psychological adaptation at the first intake. However, against the background of regular and prolonged intake, even the dosages recommended by the doctor, the body develops dependence. At first, it is not so noticeable, but over time, the patient feels that the usual therapeutic amount of barbiturate no longer has the necessary effect. There is a need to exceed the dosage: the so-called tolerance develops, the person becomes dependent and can no longer sleep normally without such drugs. Sooner or later, this can lead to poisoning.

As for children, they can get poisoned by barbiturates if there is no special place in the house to store medicines. Having free access to medicines, a child can use this or that drug without the knowledge of adults: such a situation often ends tragically, so parents should take all necessary safety measures to prevent medicines from falling into children's hands.

[ 7 ]

Pathogenesis

The vast majority of cases of barbiturate poisoning occur intentionally: the goal is to cause death.

When ingested in excessive non-therapeutic doses, barbiturates inhibit the functional activity of the brain stem and cerebral cortex. As a result, the patient loses consciousness, falls into a comatose state, and respiratory disorders occur. Reflex activity is impaired in the form of a lack of tendon, pain, and tactile reflexes.

Due to the toxic effect of barbiturates on the vasomotor center, vascular tone decreases, and contractile activity of the heart muscle suffers. Severe hemodynamic changes develop:

• blood pressure drops rapidly;
• cardiac output decreases;
• the volume of circulating blood decreases;
• tissue oxygen starvation occurs.

Hemodynamic disorders lead to metabolic imbalance, thermoregulation failure, and dehydration.

Excessive concentrations of barbiturates in the blood cause intoxication of the hypothalamic-pituitary system. As a result, diuresis decreases (even anuria is possible) and the nitrogen level increases (azotemia).

In severe cases, vasomotor and respiratory paralysis occurs, followed by death of the patient due to profound cardiac and respiratory failure.

[ 8 ], [ 9 ], [ 10 ]

Symptoms barbiturate poisoning

Unfortunately, barbiturate poisoning is not always recognized at the initial stage, because the severity of intoxication depends on many factors:

• category of barbiturate, its pharmacological characteristics;
• the amount of medication taken;
• general condition of the body at the time of taking the medication;
• the presence of food, alcohol or other medications in the stomach;
• the patient's age, the functionality of the liver and other organs.

The first signs of poisoning may be different, but one of them is always the same: sleep. The initial phase of such sleep proceeds with the preservation of reflexes, after which a deep phase begins: sensitivity is dulled, a person stops feeling pain and touch, hearing sounds.

The degree of poisoning is determined by the presence of corneal and pupillary reflexes.

The corneal reaction manifests itself as a sharp closing of the eyelids in response to irritation of the cornea (for example, with a cotton swab or the edge of a clean bandage). The norm for such a reaction is the closing of both eyes when one is irritated.

The corneal reflex may remain intact with relatively mild barbiturate poisoning. Absence of the reflex indicates severe intoxication.

The pupillary reaction consists of a change in the pupil diameter. With the eye closed or in the dark, the pupil dilates. When exposed to a light beam, it constricts. The absence of such a reaction indicates a severe degree of barbiturate overdose.

Changes in the respiratory system go through four stages:

• Stage I: the breathing rate decreases.
• Stage II: breathing becomes shallow.
• Stage III: breathing becomes intermittent.
• Stage IV: breathing stops.

If a patient has taken a large amount of barbiturates, paralysis of the brain center responsible for breathing occurs, which leads to a complete cessation of respiratory function.

Against the background of respiratory disorders, the carbon dioxide content increases and the oxygen level in the body decreases, acidosis develops. At the same time, blood pressure decreases, vascular tone is disrupted, and the contractility of the heart muscle decreases. The pulse becomes weakened, threadlike, and in severe poisoning, it disappears altogether.

Diuresis is impaired as a result of increased secretion of vasopressin and deterioration of blood supply to the kidneys.

Intestinal motility slows down, and the production of gastric juice slows down.

The course of oxidative reactions in the body worsens, thermoregulation is disrupted, which manifests itself as hypothermia.

Pulmonary congestion develops, air circulation becomes difficult, and the bronchial lumen decreases. This can cause the development of inflammatory processes and atelectasis.

In clinical practice, barbiturate poisonings are registered mainly with medium-term and long-term effects. Such drugs are more accessible, they can accumulate in the body, have a low metabolism and are often taken by patients without the consent of a doctor.

Poisoning with short-acting barbiturates is usually easily treated in outpatient settings: such drugs are quickly metabolized in the liver. Self-healing is observed within half an hour, provided that the lungs are ventilated normally.

Stages

It is customary to distinguish the following stages in barbiturate poisoning:

1. "Falling asleep": the person becomes sleepy, indifferent, and the degree of reaction to irritants decreases. However, contact with the victim can be established.
2. "Shallow coma": consciousness fades, pupils dilate briefly, cough and swallow reflexes weaken, tongue may fall back. Body temperature may rise slightly.
3. "Deep coma": reflex reactions are not observed, the functions of the main organs and systems are impaired. The respiratory function is impaired due to the suppression of the respiratory center: breathing is arrhythmic, further paralysis and arrest may develop.
4. "Post-comatose state": the patient regains consciousness. At first, capriciousness, a decline in the psycho-emotional state, sleep disorders, and, less often, weak motor arousal are observed.

[ 11 ], [ 12 ]

Forms

In medicine, the following types of barbiturate poisoning are distinguished, depending on the severity of intoxication:

• Mild variant: the victim is asleep, but attempts to wake him up are successful. Reflex reactions are preserved, breathing is even, blood pressure readings are within normal limits.
• Average scenario: the victim is asleep and does not respond to attempts to wake him up. However, reflex reactions, respiratory function and blood pressure are within normal limits. This condition requires round-the-clock monitoring of the patient's condition: if there is no deterioration, the person wakes up on his own in about 2-3 days.
• Severe variant: tendon reactions and corneal reflex disappear, the body is not tense. Pupil reaction is slow, but it can be traced. Respiratory movements are rare, periodically interrupted. Blood pressure indicators decrease. With continuous medical monitoring and drug support, the victim can come to his senses in 5-6 days.
• Critical, especially severe variant: no reflex reactions are observed, respiratory movements are rare with regular pauses, skin and mucous tissues are cyanotic. Blood pressure indicators cannot be determined, pulse impulses are weak. There is no talk of the patient independently exiting this condition.

[ 13 ], [ 14 ]

Complications and consequences

Barbiturate poisoning is characterized by the following adverse complications:

• development of a comatose state, various neurological disorders;
• problems with respiratory function;
• heart disorders;
• trophic disorders, renal pathologies.

Respiratory problems are the most common and life-threatening complications associated with comatose states. Such disorders are recorded in more than half of people with barbiturate poisoning. If respiratory resuscitation measures are not carried out in a timely manner, the patient may die.

Even after the acute respiratory distress has been relieved, the victim may show signs of respiratory failure caused by the development of pneumonia, tracheobronchitis, etc. This development of events is observed in every fourth patient admitted with a diagnosis of barbiturate poisoning.

Cardiac dysfunctions are manifested by tachycardia, decreased blood pressure, pulmonary edema and collapse. Functional systolic murmur is observed, heart sounds are muffled.

Trophic disorders are found in 6% of patients: necrodermatomyositis and bullous dermatitis are diagnosed, which manifests itself in the accelerated appearance of bedsores. This complication is explained by local disruption of tissue blood supply and deterioration of nerve conduction function.

Incorrect kidney function is a consequence of acute cardiovascular collapse. The patient experiences a decrease in daily diuresis and deterioration in the blood supply to the urinary organs.

With prolonged intoxication with barbiturates in moderate doses, barbiturate dependence develops, the manifestations of which are sometimes more pronounced than in heroin addicts.

What causes death?

In most cases, death occurs as a result of respiratory arrest, which is caused by depression of the respiratory center and paralysis of the respiratory system.

Less common causes of death are:

• acute liver failure;
• shock reaction followed by cardiac arrest.

[ 15 ]

Diagnostics barbiturate poisoning

Diagnostic measures are aimed at determining the etiology of poisoning. This process consists of three types of measures:

• Clinical and instrumental diagnostics are based on information collected during anamnesis, inspection of the scene, and assessment of existing clinical signs of poisoning. Additional instrumental methods may be used only after emergency care has been provided, as well as at the stage of patient recovery:

1. electrocardiography;
2. monitoring of blood pressure, pulse, temperature;
3. chest x-ray;
4. Ultrasound of the heart, internal organs;
5. spirography (spirometry);
6. electroencephalography.

• Laboratory tests allow qualitative or quantitative determination of the cause of intoxication. Biological environments in the body are examined: in particular, enzyme immunoassay, immunochemical analysis, polarization fluoroimmunoassay, etc. are carried out. These studies are associated with a specific antigen-antibody reaction: the antigen is a barbiturate isolated from the biological environment of the victim, and the antibody is a ready-made IgG fraction of the blood of an immunized animal. Such tests are referred to as express diagnostic procedures. If available, special test strips "Immunochrome-barbiturates-express" can be used, which are one of the options for immunochromatographic analysis.
• Pathological morphological signs of barbiturate poisoning are a postmortem assessment carried out by forensic experts. At the scene of the incident, the expert must determine the cause of intoxication, the type of toxic agent, its quantity and method of administration, as well as the exact time of poisoning.

[ 16 ], [ 17 ], [ 18 ], [ 19 ], [ 20 ]

Differential diagnosis

Differential diagnosis of barbiturate poisoning is carried out with the following conditions:

• acute cerebrovascular accident;
• acute neuroinfection;
• closed craniocerebral injury;
• cardiogenic shock;
• other endogenous or exogenous intoxications.

The basic difference between barbiturate poisoning and other acute brain injuries is the absence of clearly expressed neurological signs. Strokes and post-traumatic pathologies are not accompanied by simultaneous sudden depression of consciousness, acute failure of cardiac activity and renal function.

In barbiturate poisoning, the meningeal signs typical of acute meningitis or subarachnoid hemorrhage are not observed.

Treatment barbiturate poisoning

If the victim is conscious, he can be helped before the ambulance arrives by washing out the stomach (inducing vomiting). In all other cases, emergency care is provided by doctors: conducting probing, providing ventilation of the lungs.

In hospital settings, treatment involves the use of the following methods:

• infusion therapy, restoration of water-electrolyte and acid-base balance;
• forced diuresis;
• hemodialysis and/or hemosorption procedures.

To speed up the removal of toxic substances from the body and ensure the release of excess fluid, the patient is given diuretics intravenously. In severe cases of poisoning, drip infusion of saline or 5% glucose is indicated (if the excretory capacity of the kidneys is preserved).

Early hemodialysis is indicated in cases of severe poisoning with long-acting barbiturates. The hemosorption procedure helps to speed up the patient's recovery from a comatose state: it is especially effective in cases of poisoning with short-acting barbiturates, the removal of which by hemodialysis is ineffective.

In case of respiratory dysfunction, tracheal intubation and artificial ventilation are used.

• Hemodialysis is a procedure for extrarenal blood purification, in which blood is “pumped” through a hemodialysis barrier installed in a special device. This method is effective at high concentrations of barbiturates, due to the fact that a large number of toxic substances bind to plasma proteins, which are unable to penetrate the purification membrane.
• Hemosorption is a blood purification procedure using a sorbent agent, such as activated carbon. The purification takes place outside the victim's body.

Emergency care for barbiturate poisoning

Barbiturate poisoning always requires emergency assistance for the victim. The algorithm of emergency actions looks like this: first of all, it is necessary to eliminate the toxic substance from the digestive system, remove it from the bloodstream, facilitate the respiratory function and improve the heart function.

Cleansing the stomach involves rinsing it (as early as possible). The volume of water for rinsing is not less than 12 liters, the procedure can be repeated.

If the patient's consciousness is preserved, the procedure is carried out by artificially inducing vomiting (after preliminary intake of several cups of water, or a weak solution of potassium permanganate, or a solution of mustard powder - one teaspoon of powder per 200 ml of warm water). The use of emetic drugs, subcutaneous injection of 1 ml of 0.5% apomorphine is also allowed.

To speed up the removal of barbiturates from the stomach, the victim is given an aqueous suspension of activated carbon (at least 20 g of the drug, or more). Important: after 10 minutes, all the carbon suspension should be removed from the stomach (vomiting should be induced) so that the absorption of the toxic substance does not become reversible. To remove barbiturates that have managed to get into the intestinal sections of the digestive system, laxatives are suitable (sodium sulfate, better known as "Glauber's salt", is optimal; castor oil is not recommended for this purpose).

To speed up the purification of blood from toxins, the patient is asked to drink a lot of fluids while taking diuretics. A conscious patient is given large volumes of plain clean water. Patients with impaired consciousness are given intravenous saline and/or 5% glucose solution. These measures are appropriate if the excretory capacity of the kidneys is preserved.

If there are significant respiratory disorders, then intubation, bronchial drainage, and connection to a ventilator may be possible. If the disorders are not so pronounced, then respiratory analeptics may be used.

• To avoid inflammatory processes in the lungs, antibiotic therapy is prescribed;
• to normalize vascular tone, vasoconstrictor drugs are used;
• cardiac glycosides are prescribed to improve cardiac function;
• When cardiac activity stops, adrenaline is injected into the left ventricle, followed by chest massage.

Antidotes in the form of specific therapy retain their effectiveness only at the initial "toxicogenic" stage of barbiturate poisoning: they can be used only with reliable clinical and laboratory confirmation of the corresponding intoxication. In all other cases, the antidote can have the opposite effect and worsen the intoxication.

The antagonist (antidote) of barbiturates is considered to be 0.5% Bemegride, which excites the central nervous system, facilitates breathing and activates blood circulation. In case of poisoning, 1 to 20 ml of 0.5% solution is administered intravenously slowly.

[ 21 ]

Medicines for barbiturate poisoning

When a comatose state develops, a 20% solution of camphor, 10% caffeine, 5% ephedrine, as well as a subcutaneous injection of cordiamine (2-3 ml every 3-4 hours) are administered.

Intensive infusion therapy involves the infusion of plasma substitutes (hemodez, polyglucin). Antibiotic therapy, vitamin therapy, and, in case of hypotension, the administration of 0.2% norepinephrine and 0.5% dopamine (1 ml intravenously in 0.4 l of polyglucin) are prescribed.

The administration of cardiac glycosides (corglycon, strophanthin) and vasoconstrictor drugs (mesaton, glucocorticosteroids) is indicated.

Acidosis is eliminated by intravenous administration of 4% sodium bicarbonate in an amount of up to 300 ml.

If the temperature rises, a lytic mixture consisting of 2.5% aminazine and 2.5% diprazine is administered intramuscularly.

To avoid complications and side effects in the form of allergic and hypersensitivity reactions, the patient must be constantly under the supervision of a medical specialist.

Vitamins for barbiturate poisoning are administered intramuscularly:

• vitamin B ₁ and B ₆ in the form of 5% solutions, 6-8 ml;
• vitamin B ₁₂ in the amount of 500 mcg (group B vitamins are not administered simultaneously!);
• vitamin C in the form of a 5% solution, 5-10 ml;
• ATP in the form of a 1% solution, 6 ml per day.

Physiotherapy treatment

Physiotherapy can be one of the methods of physical recovery of a patient who has survived barbiturate poisoning. The therapy is based on the influence of natural (air, sunlight, water) and artificial (electric current, magnetic field) physical factors.

Basic methods of physiotherapy include:

• balneotherapy (drinking mineral waters, mud wraps);
• climatotherapy (salt caves, pine and mountain air);
• hydrotherapy, therapeutic showers and baths, thermal springs;
• inhalation of medications to improve the functioning of the respiratory tract;
• mechanical treatment (physical therapy, manual therapy, massages).

Physiotherapy is not included in the treatment and rehabilitation program if the patient has the following contraindications:

• tumor processes;
• acute purulent and infectious processes;
• tuberculosis;
• decompensated conditions;
• CNS lesions with impaired sensitivity.

Folk remedies

Treatment of barbiturate poisoning with folk remedies is allowed only after approval of the doctor, and only in case of mild intoxication. In case of severe poisoning, home treatment, unfortunately, will not help: precious time necessary for saving the life of the victim will be lost.

How can you help a patient with mild barbiturate poisoning?

• Grate a piece of ginger root, about half the size of a matchbox, on a fine grater. Pour 200 ml of boiling water over the grated root, let it sit for 10 minutes, then filter and drink. Repeat the procedure three times a day, the course of treatment is 4-7 days.
• Pour boiling water (200 ml) over 10 dry clove buds. Keep covered for about half an hour. Take 1 tbsp of infusion every 30-40 minutes throughout the day.
• Take berries or leaves of viburnum (50 g or 100 g respectively), pour one liter of boiling water into a thermos, and leave for an hour. Filter the infusion and cool. Drink throughout the day between meals (the entire volume of the infusion must be drunk within 24 hours).
• Take 50 g of rose hips, pour one liter of boiling water into a thermos, and leave for about three hours. Then filter the infusion and add 50 g of honey. Drink 250 ml three times a day, between meals.

Simple cases of barbiturate poisoning can be treated with folk remedies: it is important to follow a drinking regimen to speed up the removal of toxic substances from the body. If the case of poisoning is complex, then you will not be able to do without the help of a doctor: there is a risk of developing serious complications, up to and including the death of the victim.

[ 22 ], [ 23 ], [ 24 ]

Herbal treatment

Medicinal plants are considered to be very effective in treating all kinds of poisoning. However, you can trust such remedies only in cases of mild barbiturate poisoning: moderate and severe intoxication requires urgent medical intervention. We offer you the following simple recipes based on the use of herbs:

• Take 2 teaspoons of dried linden flowers, brew 200 ml of boiling water, and leave for 30 minutes under a lid. Drink this tea 4-5 times a day for at least two days. Linden flowers will help restore the performance of a weakened body.
• One tablespoon of mint leaves is brewed with 250 ml of boiling water, kept under a lid for two hours, filtered. Drink a large sip of the infusion every two hours until the condition is stable.
• Brew 2 teaspoons of fennel seed in 200 ml of boiling water, keep covered for 20 minutes. Take the remedy three times a day, 100 ml.
• Brew 1 tbsp. chicory and 1 tsp. St. John's wort in two 200 ml glasses of boiling water. Drink one sip every 2 hours. Duration of treatment is 2 days.

Variations are possible among the recipes: for example, marshmallow, valerian root, dill, greens and dandelion flowers can also be added to the mixtures.

Homeopathy

Mild barbiturate poisoning can be eliminated with homeopathy. Such remedies can also help at the stage of recovery of the body after the relief of acute symptoms of intoxication: homeopathic granules and drops will accelerate the removal of toxic substances from the body, normalize the water-electrolyte balance.

The drugs listed below are taken in potency 6C or 30C, however it will be better if the exact treatment regimen is determined by the doctor on an individual basis.

• Arsenicum will help with physical weakness, abdominal pain, excessive anxiety and restlessness, as well as in cases where intoxication is accompanied by a disruption of digestive processes, or the patient’s refusal to eat.
• Carbo vegetabilis is especially helpful in cases of evening poisoning, when the patient experiences severe weakness, inability to get out of bed, cold sweat, weak pulse, and cyanosis of the lips.
• Quinine is necessary at the first signs of dehydration, as well as in cases where barbiturate poisoning is accompanied by aching bones and joints, exhaustion, irritability and increased general sensitivity.
• Lycopodium will help with symptoms of indigestion and liver dysfunction.
• Nux vomica is used at the stage of recovery after barbiturate poisoning: to normalize sleep, stabilize the nervous system, and improve digestive function.

Prevention

Often barbiturate poisoning occurs as a result of irresponsible attitude to storing medications, as well as due to absent-mindedness or ignorance. To avoid such situations, medications should be stored in hard-to-reach places, in a dark and dry place. Medications should not be stored without names, without packaging (for example, in bulk).

You should not rely on your own knowledge and skills and prescribe medications to yourself: treatment with barbiturates can only be prescribed by a medical specialist.

If barbiturates were prescribed by a doctor, then during treatment you should not drink alcohol under any circumstances: these substances are incompatible and potentiate each other's effects. In addition, it is unacceptable to make your own adjustments to the treatment regimen proposed by the doctor.

[ 25 ]

Forecast

When making a prognosis for barbiturate poisoning, doctors take into account all the symptoms, as well as the general health and age of the victim. If the corneal reaction is preserved, breathing is stable, and blood pressure is normal, then the prognosis is considered favorable.

A poor prognosis with the risk of patient death can be discussed in the presence of the following negative signs:

• loss of corneal reaction;
• loss of pupillary response;
• loss of response to stimuli in general;
• cyanosis of the skin and mucous membranes;
• respiratory disorders;
• drop in blood pressure readings.

The severity of poisoning and the further prognosis of barbiturate poisoning are determined after first aid has been provided.