Where Myth meets Fantasy

1. Where Myth meets Fantasy Dr Laura Martin Registrar Department of Emergency Medicine

2. 0530 ambulance communication... • 8 minutes until arrival at ED • 2 female patients mid twenties • found unconscious outside a nightclub on K road • both status 2 (unstable) • patient A: GCS 5, P110, BP 96/64 • patient B: GCS 7, P100, BP110/68

3. On arrival in ED • Collateral History from male companion • both women had attended a dance party • ingested minimal alcohol • ingested a “clear liquid” 30min prior to collapsing • no other medical history available

4. Patient A • Primary survey • airway patent, placed in a hard collar • respiration rate 10/min • good breath sounds bilaterally • SpO2 100% on 6L/min • HR 108 BP 98/70 well perfused peripheries • GCS 6/15 (E1 V1 M4) • PERL 5mm

5. Secondary Survey • “Glitter sign” positive • Odour of ethanol • T 35.6oC • Abrasion and haematoma left supraorbital ridge • No other evidence of trauma • Rest of examination was unremarkable • BM glucose normal

6. Management • 0.9% NaCl 1000ml I.V stat • Standard rapid sequence induction and intubation • Ventilation • Ongoing sedation and paralysis

7. Investigations • FBC, U&E’s normal • ABG unremarkable • ECG sinus tachycardia QTc 0.38s • Ethanol 12 mmol/L • Paracetamol/salicylate levels negative • CXR no evidence of aspiration • CT head normal • C-spine X-rays normal

8. Disposition • Uneventful DCCM admission and early extubation • Self Discharged

9. Patient B • Primary Survey • Patent airway • Respiratory rate14 bpm normal breath sounds • HR 100, BP 110/74 • GCS 8/15 (E1 V2 M5) • PERL 6mm

10. Secondary Survey • T 36.9o C • no evidence of trauma • during initial assessment roused rapidly to a GCS 14 (E4 V4 M6) • rest of examination was unremarkable • BM glucose normal

11. After a 4-hour, uneventful, observation period the patient was discharged to the care of her family Disposition

12. The Offending Agent • Gamma hydroxybutyrate • GHB • GBH • Fantasy • 1,4-Butanediol • one 4 B • Gamma butyrolactone • GBL • liquid G

14. GHB • Naturally occurring • Neuromodulator • Dopaminergic • GABA • Endogenous opioids

15. The Facts of Fantasy • Initial excitation • Amnesia • increasing sedation • Gait ataxia • Nausea/vomiting • “Seizure-like” activity • Coma • Respiratory depression • Reduced cardiac output

16. The Magic Of Fantasy • Euphoria • Disinhibition • Enhancement of libido • Heightened sexual performance • Prolonged erection • Sensitivity to touch • Enhanced interpersonal communication

17. The Myth of Fantasy • Steep dose response curve • Inter-individual variability • Impurity of street preparations • Misinformation • Implicated in date-rape

18. Fantasy: ED issues • Intubation? • Investigation? • Decontamination? • Physostigmine • Resource issues

19. References • NEJM Vol. 344, No.2 Jan 11, 2001 p87Ann Emerg Med 37:1 Jan 2001Annal Emerg Med 31:6 June 1998 p717J of Emerg Med 18:1 Jan 1999Emerg Med Clinics N America 18:4 Nov 2000BMJ 314:35 Jan 4 1997Addiction 92:1 1997 p89

20. GHB Presentations

21. Disposition of Patients • 59 clinical cases • 65.5% Discharged from ED • 19.3% Admitted • 15.2% Self Discharged

22. Controversies revisited • Conservative management of the unconscious GHB patient • Value of Physostigmine • Duration of monitoring • Prevention • Toxicological screening