Case Presentation

1
Case Presentation 14

• Jim Pointer, MD
• Alameda County EMS
• Medical Director

2
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.

3
Initial Assessment

• An unconscious, twenty-ish white male
• Airway intact
• Respirations 8 per minute
• Good radial pulses
• Glascow Coma Scale 5

4
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

5
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

6
12-lead EKG
7
Past Medical History

• Non-contributory
• Patient training to be a stockbroker

8
Initial Treatment

• Non-rebrather mask 100 O2
• IV Normal Saline
• Dextrostix 90 mg/dl
• Naloxone 0.5mg IV ? No response
• Transport

9
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

10
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

11
CT Scan
Negative
12
Brief Differential Diagnosis

• Intracranial pathology
• Toxic ingestion
• CNS infection
• Metabolic disorder

13
Gamma Hydroxybutyrate (GHB)

• Emergency drug of abuse
• Promoted for health benefits
• Range of toxic effects
• Steep dose-response curve
• Party and date rape drug

14
Chemical Structure of GHB
?-Hydroxybutyric Glutamic
?-Aminobutyric Acid
Acid
Acid
15
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 1980s
• Party drug at raves
• Dietary supplements and growth hormone
  stimulators

16
Background Cont.

• 4969 ED visits in 2000 (55 in 1994)
• FDA illicet, unapproved drug (schedule I)
• Readily available on the internet

17
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
• gt 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

21
Initial GCS Scores86 GHB patients at SFGH
Glascow Coma Scale
22
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

25
References

• Chin RL, Sporer KA, Cullison B, et al. Clinical
  Course of gamma-hydroxybutyrate overdose. Annals
  of Emergency Medicine 1998 31 716-722
• OConnell T, Kaye L, Plusay JJ.
  Gamma-hydroxybutyrate a newer drug of abuse.
  American Family Physician 2000 62
  2478-83