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A Collapsed Giant

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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  1. A Collapsed Giant Dr. Jacky Sia RHAED

  2. TSKAED 1998 • No computer system • No Toxicology database • No CMS • No internet • No urinary test.

  3. Case summary • 39-year Caucasian. • 240 lbs giant. • Well along • Collapsed and convulsion in gym.

  4. DDx of collapse Any causes that you could think of!

  5. Reading!

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

  7. Drugs before gym many more...

  8. History • another 260-lbs giant.

  9. 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.

  10. 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.

  11. Case summary • Rapid recovery 2 hours later. • DAMA despite twitching of limbs and drooling of saliva. • Dx: GHB (History) • Reason for collapse: alcohol + GHB.

  12. GHB poisoning

  13. Media interview

  14. News!

  15. Male - not exemption

  16. Layman Diagnostic kit

  17. Layman Diagnostic kit

  18. History • 1980s: over-the-counter in health stores. • Abused as recreational drugs. • 1991: ? Political reason. Banned for its excellent GA property.

  19. GHB - naturally found • Hypothalamus • Basal ganglia • Kidney • Heart • Skeletal • Brown fat tissue.

  20. Physiology • 16 times increase in GH. • Inhibit the protein breakdown. • Facilitate fat loss. • Induce hypotonia. • Enhance sexual arousal.

  21. Physiology • Colorless, odorless, tasteless. • Excellent sedation, amnesia. • “Date-rape” drug: rapid incapacitation. • No toxic metabolites, only CO2, H2O. • Normalized after 2 - 5 hours.

  22. GHB • Developed as an anesthetic due to similarity to GABA Initially marketed to bodybuilders, later became popular as a club drug.

  23. 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

  24. GHB – Recovery Time Chin RL. Clinical Course of Gamma-Hydroxybutyrate Overdose. Annals of Emerg. Med. 1998: 31: 716-722

  25. GHB – Recovery Time Conc Time

  26. 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.

  27. Back to basic • House brewed in US. • Different potencies, purities. • Different side effects. • Toxic effect unpredictable. • 30 mg/kg to 60 mg/kg.

  28. Therapeutic Value • Sleeping disorder • Narcolepsy • Alcohol withdrawal • Depression

  29. Case series By Okun, Michael S; Doering, Paul L; Bartfield, Richard B (Emedicine abstract) 2000 Emergency Medicine. via Bell&Howell Information and Learning Company

  30. Case series 1

  31. Case series 2

  32. Case series 3

  33. Case series 4

  34. Case series 5

  35. Case series 6

  36. 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.

  37. 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.

  38. ? Toxidrome Young! Normal Temp Relatively normal Pupils Deep coma Not breathing! Toxicology screening Wake up with agitation

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

  40. Drugs Combinations!

  41. Lessons 俊男 都要小心！

  42. Lessons • Wanchai: > 3 cases (1 M, 2 F) • GHB: unreported? • History, clinical signs & suspicion. • Intubate or not ? • Supportive treatment. • Further research: test kit.

  43. Thank you!

  44. 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.

  45. 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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