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A Collapsed Giant. Dr. Jacky Sia RHAED. TSKAED 1998. No computer system No Toxicology database No CMS No internet No urinary test. Case summary. 39- year Caucasian. 240 lbs giant. Well along Collapsed and convulsion in gym. DDx of collapse. Any causes that you could think of!.

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a collapsed giant

A Collapsed Giant

Dr. Jacky Sia

RHAED

tskaed 1998
TSKAED 1998
  • No computer system
  • No Toxicology database
  • No CMS
  • No internet
  • No urinary test.
case summary
Case summary
  • 39-year Caucasian.
  • 240 lbs giant.
  • Well along
  • Collapsed and convulsion in gym.
ddx of collapse
DDx of collapse

Any causes that

you could think of!

possible supplement
Possible supplement
  • EFA: ephedrine, caffeine, aspirin.
  • EFT: Ephedrine, Foskolin, Theophylline.
  • Creatine.
  • Steroids: oral, injectable.
  • Herbal extract. Thyroid extract.
  • Many more….
drugs before gym
Drugs before gym

many more...

history
History
  • another 260-lbs giant.
case summary1
Case summary
  • BP 138/86, P 76/min. Temp: 36.8C
  • GCS: 12/15
  • PERL: 3mm
  • Intermittent twitching of limbs
  • Blood sugar: 6.9 mmol.
  • Systemic review were normal.
case summary2
Case summary
  • ECG was normal.
  • No urinary for toxicology kit (1998)
  • Valium 5mg IVI.
  • To RH medical ward.
  • CBP, R/LFT, Toxicology screen, CT brain: normal.
case summary3
Case summary
  • Rapid recovery 2 hours later.
  • DAMA despite twitching of limbs and drooling of saliva.
  • Dx: GHB (History)
  • Reason for collapse: alcohol + GHB.
history1
History
  • 1980s: over-the-counter in health stores.
  • Abused as recreational drugs.
  • 1991: ? Political reason. Banned for its excellent GA property.
ghb naturally found
GHB - naturally found
  • Hypothalamus
  • Basal ganglia
  • Kidney
  • Heart
  • Skeletal
  • Brown fat tissue.
physiology
Physiology
  • 16 times increase in GH.
  • Inhibit the protein breakdown.
  • Facilitate fat loss.
  • Induce hypotonia.
  • Enhance sexual arousal.
physiology1
Physiology
  • Colorless, odorless, tasteless.
  • Excellent sedation, amnesia.
  • “Date-rape” drug: rapid incapacitation.
  • No toxic metabolites, only CO2, H2O.
  • Normalized after 2 - 5 hours.
slide22
GHB
  • Developed as an anesthetic due to similarity to GABA

Initially marketed to bodybuilders, later became popular as a club drug.

slide23
GHB
  • Mechanism of Action
    • Structural similarity to GABA, but crosses the BBB
    • Acts on GABA-B receptors
  • Clinical manifestation
    • CNS depression/euphoria (20-30 mg/kg)
    • Coma and respiratory depression seen (50-70 mg/kg)
    • Headache, ataxia, confusion, myoclonus
ghb recovery time
GHB – Recovery Time

Chin RL. Clinical Course of Gamma-Hydroxybutyrate Overdose. Annals of Emerg. Med. 1998: 31: 716-722

elimination of ghb
Elimination of GHB
  • GHB exhibits zero-order kinetics - it has no half-life.
  • Time required to eliminate half a given dose increases as the dose increases.
  • Everyone excretes GHB - it is a normal urinary metabolite. Concentrations < 10 ug/mL may be considered normal.
back to basic
Back to basic
  • House brewed in US.
  • Different potencies, purities.
  • Different side effects.
  • Toxic effect unpredictable.
  • 30 mg/kg to 60 mg/kg.
therapeutic value
Therapeutic Value
  • Sleeping disorder
  • Narcolepsy
  • Alcohol withdrawal
  • Depression
case series
Case series

By Okun, Michael S; Doering, Paul L; Bartfield, Richard B (Emedicine abstract)

2000 Emergency Medicine. via Bell&Howell Information and Learning Company

retrospective chin rl ref 14
Retrospective - Chin RL Ref 14
  • 1993 to 1996
  • 69% male with mean age 28 years.
  • Co-ingestion (alcohol, club drugs)
  • Deep coma. Hypothermia.
  • Bradycardia to AF; Hypotension.
  • Respiratory acidosis.
retrospective chin rl ref 141
Retrospective - Chin RL Ref 14
  • Must rule out AEIOU TIPS.
  • Conservative approach if history is reliable.
  • One study: 17/25 patients (GCS 3) NOT intubated.
  • Emergence feature: myoclonic jerking, confusion and combativeness.
toxidrome
? Toxidrome

Young!

Normal Temp

Relatively normal

Pupils

Deep coma

Not breathing!

Toxicology

screening

Wake up with agitation

national laboratories
National laboratories
  • Lab tests not readily available.
  • LOC: serum level 50 mg/dL.
  • Coma: serum level 260 mg/dL.
lessons
Lessons

俊男

都要小心!

lessons1
Lessons
  • Wanchai: > 3 cases (1 M, 2 F)
  • GHB: unreported?
  • History, clinical signs & suspicion.
  • Intubate or not ?
  • Supportive treatment.
  • Further research: test kit.
references
References
  • Gal l imber ti L, Canton G, Gent i le N, e t al . Gamma hydroxybutyric acid for treatment of alcohol withdrawal syndrome. Lancet 1989;2 (8666):787-9.
  • 2. Chin MY, Krentzer RA, Dyer JE. Acute poisoning from gamma hydroxybutyrate in California. West J Med 992;156(4):380-4.
  • 3. Hodges B, Everett J. Acute toxicity from homebrewed gamma hydroxybutyrate. J Am Board Fam Pract 1998;11(2):154-7.
  • 4. John Mor g entha l e r and Dan Joy. Gamma - hydroxybutyrate. Smart drug news. September 10th,
  • 1994 [v3n6].
  • 5. Ta kaha r a J, Yunok i S, Ya kushi j i W, e t a l . Stimulatory effects of gamma-hydroxybutyric acid
  • on growth hormone and prolactin release in humans. J Clin Endocrinol Metab 1977;44(5):1014-7.
  • 6. Laborit H. Sodium 4-hydroxybutyrate. Int J Neuropharmacol 1964;3:433-52.
  • 7. Laborit H. Cor relations between protein and serotonin synthesis during various activities of the central nervous system. Res Commun Chem Pathol Pharmacol 1972;3(1):51-81.
references1
References
  • 8. Vickers MD. Gamma-hydroxybutyric acid. Int Anesthesiol Clin 1969;7(1):75-89.
  • 9. Chin RL, Sporer KA, Cullison B, et al. Clinical course of gamma-hydroxybutyrate overdose. Ann Emerg Med 1998;31(6):716-22.
  • 10. Fadda F, Colombo G, Mosca E, et al. Suppression by g amma -hydroxybuty r i c a c id of e thanol withdrawal syndrome in rats. Alcohol Alcohol 1989; 24(5):447-51.
  • 11. Leikin JB, Paloucek FP. Poisoning & Toxicology Handbook, 2nd ed. Hudson, Ohio, Lexi-Comp Inc., 1995.
  • 12. Baselt RC, Cravey RH. Disposition of Toxic drugs and Chemicals in Man, 4th ed. Foster City, CA, CTI, 1995.
  • 13. Ejjenhorn MJ, Schonwald S, Ordog G, et al. Drug of Abuse. In Ejjenhorn MJ(ed):Ejjenhorn\'s Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd ed. Baltimore, Williams and Wilkins, 1997.
  • 14. Chin RL, Sporer KA, Cullison B, Dyer JE, Wu TD: Clinical course of GHB overdose. Ann Emerg Med June 1998;31:716-722.
  • 15. David GEC, Fiona YC, Brian JB, Peter DF, Roger WB. Fatalities associated with theuse of GHB and its analogue in Australasia. MJA 2004;181(6):310-313.
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