Case presentation 14
Download
1 / 25

Case Presentation 14 - PowerPoint PPT Presentation


  • 333 Views
  • Updated On :

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

Related searches for Case Presentation 14

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Case Presentation 14' - paul


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Case presentation 14 l.jpg

Case Presentation #14

Jim Pointer, MD

Alameda County EMS

Medical Director


Complaint l.jpg
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 l.jpg
Initial Assessment

  • An unconscious, twenty-ish white male

  • Airway: intact

  • Respirations: 8 per minute

  • Good radial pulses

  • Glascow Coma Scale: 5


Focused history and physical exam l.jpg
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


Pertinent findings l.jpg
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



Past medical history l.jpg
Past Medical History

  • Non-contributory

  • Patient training to be a “stockbroker”


Initial treatment l.jpg
Initial Treatment

  • Non-rebrather mask 100% O2

  • IV Normal Saline

  • Dextrostix: 90 mg/dl

  • Naloxone 0.5mg IV  No response

  • Transport


Hospital findings l.jpg
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


Lab studies l.jpg
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


Ct scan l.jpg
CT Scan

Negative


Brief differential diagnosis l.jpg
Brief Differential Diagnosis

  • Intracranial pathology

  • Toxic ingestion

  • CNS infection

  • Metabolic disorder


Gamma hydroxybutyrate ghb l.jpg
Gamma Hydroxybutyrate (GHB)

  • Emergency drug of abuse

  • Promoted for “health” benefits

  • Range of toxic effects

  • Steep dose-response curve

  • Party and “date rape” drug


Chemical structure of ghb l.jpg
Chemical Structure of GHB

-Hydroxybutyric Glutamic -Aminobutyric

Acid Acid Acid


Ghc background l.jpg
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


Background cont l.jpg
Background – Cont.

  • 4969 ED visits in 2000 (55 in 1994)

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

  • Readily available on the internet


Dosage l.jpg
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


Usage l.jpg
Usage

  • 55%: Bodybuilders

  • 41%: Weight loss

  • 27%: Sleep

  • 5%: Euphoria


Self reported symptoms l.jpg
Self-Reported Symptoms

  • 73%: Drowsiness

  • 46%: Feeling “high”

  • 41%: Dizziness

  • 32%: Increased arousal

  • 9%: Loss of peripheral vision


Clinical syndrome l.jpg
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


Initial gcs scores 86 ghb patients at sfgh l.jpg
Initial GCS Scores86 GHB patients at SFGH

Glascow Coma Scale


Serious toxicity l.jpg
Serious Toxicity

  • Trauma – head-banging

  • Aspiration pneumonia

  • Seizures

  • Asphyxiation

  • Respiratory depression – pulmonary edema

  • Co-intoxicants


Pharmacokinetics l.jpg
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


Populations at risk l.jpg
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


References l.jpg
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


ad