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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

Case Presentation #14

Jim Pointer, MD

Alameda County EMS

Medical Director

complaint
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
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
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
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
Past Medical History
  • Non-contributory
  • Patient training to be a “stockbroker”
initial treatment
Initial Treatment
  • Non-rebrather mask 100% O2
  • IV Normal Saline
  • Dextrostix: 90 mg/dl
  • Naloxone 0.5mg IV  No response
  • Transport
hospital findings
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
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
CT Scan

Negative

brief differential diagnosis
Brief Differential Diagnosis
  • Intracranial pathology
  • Toxic ingestion
  • CNS infection
  • Metabolic disorder
gamma hydroxybutyrate ghb
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
Chemical Structure of GHB

-Hydroxybutyric Glutamic -Aminobutyric

Acid Acid Acid

ghc background
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
Background – Cont.
  • 4969 ED visits in 2000 (55 in 1994)
  • FDA: “illicet, unapproved drug” (schedule I)
  • Readily available on the internet
dosage
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
Usage
  • 55%: Bodybuilders
  • 41%: Weight loss
  • 27%: Sleep
  • 5%: Euphoria
self reported symptoms
Self-Reported Symptoms
  • 73%: Drowsiness
  • 46%: Feeling “high”
  • 41%: Dizziness
  • 32%: Increased arousal
  • 9%: Loss of peripheral vision
clinical syndrome
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
serious toxicity
Serious Toxicity
  • Trauma – head-banging
  • Aspiration pneumonia
  • Seizures
  • Asphyxiation
  • Respiratory depression – pulmonary edema
  • Co-intoxicants
pharmacokinetics
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
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
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