Case Presentation #14

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 1980’s • 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 • > 50 mg/kg: coma

18. Usage • 55%: Bodybuilders • 41%: Weight loss • 27%: Sleep • 5%: Euphoria

19. Self-Reported Symptoms • 73%: Drowsiness • 46%: Feeling “high” • 41%: Dizziness • 32%: Increased arousal • 9%: Loss of peripheral vision

20. 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

23. 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 

24. 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 • O’Connell T, Kaye L, Plusay JJ. Gamma-hydroxybutyrate: a newer drug of abuse. American Family Physician 2000; 62: 2478-83