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Case Presentation #14 PowerPoint PPT Presentation

Case Presentation #14 Jim Pointer, MD Alameda County EMS Medical Director Complaint You are called to a night-club at 0200. The “bouncer” tells you that a young male patient is in the “back room”, unconscious. Initial Assessment An unconscious, twenty-ish white male Airway: intact

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Case Presentation #14

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Case presentation 14 l.jpg

Case Presentation #14

Jim Pointer, MD

Alameda County EMS

Medical Director


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Complaint

  • You are called to a night-club at 0200. The “bouncer” tells you that a young male patient is in the “back room”, unconscious.


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Initial Assessment

  • An unconscious, twenty-ish white male

  • Airway: intact

  • Respirations: 8 per minute

  • Good radial pulses

  • Glascow Coma Scale: 5


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Focused History and Physical Exam

  • Patient had “3 beers” according to his girlfriend

  • He rapidly became somnolent, then unconscious, after dropping “something” in his drink


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Pertinent Findings

  • B/P: 136/80

  • RR: 10

  • PR: 54

  • Pulse Ox: 99% (room air)

  • Pupils: non-reactive (4mm)

  • Neuro: GCS: 4 (occ. myoclonic movements)

  • EKG: occasional U waves present


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12-lead EKG


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Past Medical History

  • Non-contributory

  • Patient training to be a “stockbroker”


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Initial Treatment

  • Non-rebrather mask 100% O2

  • IV Normal Saline

  • Dextrostix: 90 mg/dl

  • Naloxone 0.5mg IV  No response

  • Transport


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Hospital Findings

  • Unconscious young male in NAD

  • Vital signs: B/P – 134/78, PR – 52, RR – 9, Temp – 96.8 (rectally), Pulse Ox – 100%

  • Neuro:

    • pupils 3-4 mm, non-reactive and equal

    • Absent deep tendon reflexes

    • Myotonic jerks

    • Minimal response to painful stimuli


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Lab Studies

  • CBC: WBC – 10.2K, H & H – 16.2/49.3

  • Chemistries: BUN, creatinine, electrolytes, LFTs, glucose – WNL

  • Tox Screen: negative for drugs of abuse

  • Blood Alcohol: 0.09


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CT Scan

Negative


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Brief Differential Diagnosis

  • Intracranial pathology

  • Toxic ingestion

  • CNS infection

  • Metabolic disorder


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Gamma Hydroxybutyrate (GHB)

  • Emergency drug of abuse

  • Promoted for “health” benefits

  • Range of toxic effects

  • Steep dose-response curve

  • Party and “date rape” drug


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Chemical Structure of GHB

-Hydroxybutyric Glutamic -Aminobutyric

Acid Acid Acid


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GHC - Background

  • GHB and precursors, GBL and I,4BD are frequently abused

  • First developed as anesthetics in 1960

  • Cuurently used in narcolepsy trials

  • Became popular in 1980’s

    • Party drug at “raves”

    • Dietary supplements and growth hormone stimulators


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Background – Cont.

  • 4969 ED visits in 2000 (55 in 1994)

  • FDA: “illicet, unapproved drug” (schedule I)

  • Readily available on the internet


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Dosage

  • Rapidily crosses blood-brain barrier

  • 10 mg/kg: anxiolytic effects

  • 20-30 mg/kg: somnolence to euphoria

  • 30 mg/kg: sleep, hallucinations, myoclonia

  • 50 mg/kg: anesthesia

  • > 50 mg/kg: coma


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Usage

  • 55%:Bodybuilders

  • 41%:Weight loss

  • 27%:Sleep

  • 5%:Euphoria


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Self-Reported Symptoms

  • 73%:Drowsiness

  • 46%:Feeling “high”

  • 41%:Dizziness

  • 32%:Increased arousal

  • 9%:Loss of peripheral vision


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Clinical Syndrome

  • Rapidly decreasing LOC

  • Relatively intact B/P and respirations

  • Minimal absent DTRs

  • Non-reactive pupils of variable size

  • Bradycardia

  • Mild reversible hypothermia

  • Vomiting within one hour of ingestion

  • Incontinence

  • Agitation/combativeness


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Initial GCS Scores86 GHB patients at SFGH

Glascow Coma Scale


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Serious Toxicity

  • Trauma – head-banging

  • Aspiration pneumonia

  • Seizures

  • Asphyxiation

  • Respiratory depression – pulmonary edema

  • Co-intoxicants


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Pharmacokinetics

  • Time to peak: 25-45 minutes

  • Hepatic metabolism

  • Levels decrease rapidly over several hours

    • 8 hours serum

    • 12 hours urine

  • Urine may be preferred testing medium

  • Steep dosage response curve

    • LOC dose (50-60 mg/kg) less than 2 times the recreational dose (35 mg/kg)

75-100 mg/kg dose


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Populations at Risk

  • Recreational users – raves etc.

  • Users for “health benefits” – bodybuilders, weight loss, insomnia, anxiety, depression

  • Addicts

  • Intoxicated drivers

  • Victims of surreptitious drugging

  • Victims of accidental ingestions


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References

  • Chin RL, Sporer KA, Cullison B, et al. Clinical Course of gamma-hydroxybutyrate overdose. Annals of Emergency Medicine 1998; 31: 716-722

  • O’Connell T, Kaye L, Plusay JJ. Gamma-hydroxybutyrate: a newer drug of abuse. American Family Physician 2000; 62: 2478-83


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