A collapsed giant
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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

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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!


Reading

Reading!


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.


Ghb poisoning

GHB poisoning


Media interview

Media interview


A collapsed giant

News!


Male not exemption

Male - not exemption


Layman diagnostic kit

Layman Diagnostic kit


Layman diagnostic kit1

Layman Diagnostic kit


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.


A collapsed giant

GHB

  • Developed as an anesthetic due to similarity to GABA

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


A collapsed giant

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


Ghb recovery time1

GHB – Recovery Time

Conc

Time


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


Case series 1

Case series 1


Case series 2

Case series 2


Case series 3

Case series 3


Case series 4

Case series 4


Case series 5

Case series 5


Case series 6

Case series 6


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.


Drugs combinations

Drugs Combinations!


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.


A collapsed giant

Thank you!


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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