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GHB and A&E: Three part question Conclusions Questions/DiscussionA case of GHB overdosePre-hospital: 999 call young male found collapsed in night club 0230hrs ? fitted GCS 3, spontaneous respiration sats 99% on air, p 67 BM normal Incontinent, Laceration to chin p= A&E arrivalA: breathing spontaneously, C-spine immobilised. B: spontaneous respiration, rate 10 bpm, not cyanosed C: CRT <2s p60, BP 110/60, ECG normal D: GCS 3, PERL 5mm, plantars normal E: Temp 36Z,UJ  ManagementERegistrar alerted Cardiac monitor IV access naloxone 400mg no effect EF, Further investigations vEthanol levels- 5mg/l ABG- hypercapnia, hyperkalaemia Routine bloods, inc poison screen X-ray C-spine and skull- NAD vw,  B Further managementLog roll NAD, PR NAD Supportive care Anaesthetist and CT alerted ?HI 15 mins later spontaneous recovery GCS 15- discharged home in morning Confirmed ingestion liquid ecstasy HcGHB- What is it?Naturally occurring, 4-carbon compound with a structure similar to gamma-aminobutyric acid (GABA). Neurotransmitter stimulates GH and prolactin Initially used as anaesthetic agent ,I 3 %/( Gamma oh, GBH, Liquid X, Liquid ecstasy)) The Rise of GHBResurgence of GHB in late 1980s in body builders and dieters Sale banned in USA in 1990 Popular in nightclubs in UK since 1994 Possession not an offence    ManufactureyAvailable over internet Floor cleaner and sodium hydroxide Powder or clear colourless solution Usually in plastic bottles   PharmacologyMetabolite and precursor of GABA GABA-B receptors Biphasic dopamine response Well absorbed orally, readily crosses BBB Half-life increases with larger doses Effects potentiated by alcohol$!/o "O  !  Use and abuseEuphoria, increased energy, happiness, desire to socialize, mild disinhibition, enhanced sexual experience Effects within 15-60 mins CNS depressant Childbirth, narcolepsy, alcohol/ opiate withdrawal, psychotherapy ,A 2T# ToxicityDrowsiness, dizziness, N&V Ataxia, incoordination Sedation, myoclonic jerks cf seizures, LOC, coma Sporadic agitation Pupils variable $d% c># <$  Toxicity (2)~Bradycardia, hypotension Respiratory depression Hypothermia Burns to the lips and oropharynx Effects typically last 3-6hrs $e g$ I !%Presentation to A&E79% of GHB users are male. Two thirds aged 18-25 years Two thirds of patients present with a GCS of less than 9, one third presenting with a GCS of 3. Friends or witnesses, parties/nightclubs Ambulance crew Not obviously alcohol Self-extubation 8Z9__  ' Differentials?Hypoglycaemia/HONK HI-extra/subdural SAH Status Drug toxicity( ManagementABC`s ABG`s, ECG Exclude other causes, naloxone Lab test not readily available Supportive including muscle relaxants Intubation/ventilation Consider reversal: physostigmine, neostigmine Gastric lavage unhelpfulZb'F     , Complicationsj Bradycardia Hypotension Hypothermia Conduction abnormalities Apnoea Aspiration of gastric contents Death 0ZjZj j _+Outcomes^Typically spontaneous, rapid, full recovery Often no memory of events Consider sexual assault-Three part question [In patients presenting to A&E with coma what are the features associated with GHB toxicity?0Search strategyx(Gammahydroxybutyrate OR GHB) AND (Emergency Department OR poisoning OR toxicity OR coma) 43 articles found 6 relevant xyd2Boyce, Padgham et al\Case series from UK Seven patients Noted bradycardia, hypothermia and respiratory depression) )3$MMWR Minnesota, New Mexico and TexasvMorbidity and mortality meeting in USA Case series of seven patients from two ED`s 34 cases from New Mexico and Texas 9 New Mexico14 cases Ages ranged from 14 to 36 nine males Five (36%) persons had ingested ethanol Symptoms: nausea/vomiting obtundation bradycardia, syncope seizures confusion combativeness respiratory depression ,p  D:Texas920 cases Ages ranged from 11 to 41 years; 13 males Ten ingested ethanol and/or other drugs. Ten patients were admitted to the hospital from the ED. Symptoms and signs: obtundation, prolonged unconsciousness, respiratory depression, nausea/vomiting, confusion, tremors/twitching, tachycardia, and combativeness":Z9 4Li, Stokes, Woeckener Literature review Noted majority young males Respiratory depression, hypothermia, hypercapnia, bradycardia and hypotension Seizure activity/ myoclonic movements No effect of naloxone Agitation with stimulation when GCS 3PS  # '5Li, Stokes, Woeckener (2) Case series of seven patients No seizures No effect of naloxone Aggression on stimulation ECG changes All confirmed GHB intake7A6 Ryan, StellCase report series of five patients in UK 3 males 2 females Seizures, hypothermia, hypotension, hypocapnia and bradycardia All confirmed GHB intake ,a  7Chin, Sporer et alRetrospective series of case reports over three years N=88 69% male, mean age 28 years. 39% coingestion of ethanol, 28% other psychoactive drugs 28% GCS of 3, 33% GCS 4-8\ D8Chin, Sporer et alMean time to consciousness GCS<13 =146 mins 31% temp <35, 36% asymptomatic bradycardia 11% hypotensive ABGs measured in <50%, 25% of these mild resp acidosis 30% had episode of emesis b'!  %%1 DrawbacksfMost small series case reports GHB use not always proven Varying investigations Different populations ; SummaryCluster of features characteristic of GHB toxicity Management of airway and respiratory depression essential Recover with supportive management <! ConclusionsDiagnostic challenge but one that must be considered Recognition will decrease morbidity and mortality as well as unnecessary use of resources Increasing occurrence and requires further study ># References1) Li J, Stokes SA, Woeckener A. A tale of novel intoxication: a review of the effects of gamma-hydroxybutyric acid with recommendations for management. Ann Emerg Med. 1998 Jun;31(6):729-36. Review. 2) Li J, Stokes SA, Woeckener A. A tale of novel intoxication: seven cases of gamma-hydroxybutyric acid overdose.Ann Emerg Med. 1998 Jun;31(6):723-8. 3) Chin RL, Sporer KA, Cullison B, Dyer JE, Wu TD. Clinical course of gamma-hydroxybutyrate overdose.Ann Emerg Med. 1998 Jun;31(6):716-22. 4)Boyce SH, Padgham K, Miller LD, Stevenson J. Gamma hydroxybutyric acid (GHB): an increasing trend in drug abuse. 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A recent study noted that two thirds of patients present with a GCS of less than 9, with one third presenting with a GCS of 3. One unique aspect of GHB-induced coma is sporadic violent agitation, usually accompanying stimuli such as intubation attempts. The coma typically resolves completely and rapidly after 3-6 hours. Seizurelike movements and myoclonus are common, particularly when descending into unconsciousness or upon reemergence. Cardiovascular Bradycardia occurs in approximately 36% of ingestions. This appears to be related to the depressed level of consciousness and is easily reversed with atropine. Hypotension Hypotension occurs in approximately 10% of GHB ingestions. This usually is associated with co-ingestion of GHB and alcohol or another drug and usually is mild. If hypotension is not readily resolved by stimulation or atropine administration, another ingestion or co-ingestion must be considered. Pulmonary Respiratory depression, evidenced by bradypnea to frank apnea, often occurs. Decreased breath sounds and rales may indicate aspiration. Gastrointestinal Nausea and vomiting are common with GHB ingestion and often accompany reemergence from unconsciousness. Other Mild hypothermia has been reported in about 70% of cases. Burns to the lips and oropharynx may represent caustic injury from concomitant lye ingestion. 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