A Collapsed Giant Dr. Jacky Sia RHAED. TSKAED 1998 No computer system No Toxicology database No CMS...
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Transcript of A Collapsed Giant Dr. Jacky Sia RHAED. TSKAED 1998 No computer system No Toxicology database No CMS...
Possible supplement EFA: ephedrine, caffeine, aspirin. EFT: Ephedrine, Foskolin, Theophylline. Creatine. Steroids: oral, injectable. Herbal extract. Thyroid extract. Many more….
Case summary BP 138/86, P 76/min. Temp: 36.8C GCS: 12/15 PERL: 3mm Intermittent twitching of limbs Blood sugar: 6.9 mmol. Systemic review were normal.
Case summary ECG was normal. No urinary for toxicology kit (1998) Valium 5mg IVI. To RH medical ward. CBP, R/LFT, Toxicology screen, CT
brain: normal.
Case summary Rapid recovery 2 hours later. DAMA despite twitching of limbs and
drooling of saliva. Dx: GHB (History) Reason for collapse: alcohol + GHB.
History 1980s: over-the-counter in health
stores. Abused as recreational drugs. 1991: ? Political reason. Banned for its
excellent GA property.
Physiology 16 times increase in GH. Inhibit the protein breakdown. Facilitate fat loss. Induce hypotonia. Enhance sexual arousal.
Physiology Colorless, odorless, tasteless. Excellent sedation, amnesia. “Date-rape” drug: rapid incapacitation. No toxic metabolites, only CO2, H2O. Normalized after 2 - 5 hours.
GHB
Developed as an anesthetic due to similarity to GABA
Initially marketed to bodybuilders, later became popular as a club drug.
O
OH
H2N
GABA
O
OH
HO
GHB
GHB Mechanism of Action
Structural similarity to GABA, but crosses the BBB
Acts on GABA-B receptors Clinical manifestation
CNS depression/euphoria (20-30 mg/kg) Coma and respiratory depression seen (50-70
mg/kg) Headache, ataxia, confusion, myoclonus
GHB – Recovery Time
Chin RL. Clinical Course of Gamma-Hydroxybutyrate Overdose. Annals of Emerg. Med. 1998: 31: 716-722
Elimination of GHB GHB exhibits zero-order kinetics - it has
no half-life.
Time required to eliminate half a given dose increases as the dose increases.
Everyone excretes GHB - it is a normal urinary metabolite. Concentrations < 10 ug/mL may be considered normal.
Back to basic House brewed in US. Different potencies, purities. Different side effects. Toxic effect unpredictable. 30 mg/kg to 60 mg/kg.
Case series
By Okun, Michael S; Doering, Paul L; Bartfield, Richard B (Emedicine abstract)
2000 Emergency Medicine. via Bell&Howell Information and Learning Company
Case series 2
Age 20 man
GCS 3
Temp 35.8
RR Labour
Toxi screen Alcohol
ET +
Withdraw 1 hr., agitation
Case series 5
Age 28 man
GCS 4
Temp 35.7
RR Shallow
Toxi screen Alcohol, cocaine
ET +
Withdraw 1 hour
Case series 6
Age 22 lady
GCS 3
Temp UK
RR Shallow
Toxi screen Alcohol, Amphetamine
ET -ve
Withdraw 7 hours
Retrospective - Chin RL Ref 14
1993 to 1996 69% male with mean age 28 years. Co-ingestion (alcohol, club drugs) Deep coma. Hypothermia. Bradycardia to AF; Hypotension. Respiratory acidosis.
Must rule out AEIOU TIPS. Conservative approach if history is
reliable. One study: 17/25 patients (GCS 3) NOT
intubated. Emergence feature: myoclonic jerking,
confusion and combativeness.
Retrospective - Chin RL Ref 14
National laboratories
Lab tests not readily available. LOC: serum level 50 mg/dL. Coma: serum level 260 mg/dL.
Lessons Wanchai: > 3 cases (1 M, 2 F) GHB: unreported? History, clinical signs & suspicion. Intubate or not ? Supportive treatment. Further research: test kit.
References Gal l imber ti L, Canton G, Gent i le N, e t al . Gamma hydroxybutyric acid for
treatment of alcohol withdrawal syndrome. Lancet 1989;2 (8666):787-9. 2. Chin MY, Krentzer RA, Dyer JE. Acute poisoning from gamma
hydroxybutyrate in California. West J Med 992;156(4):380-4. 3. Hodges B, Everett J. Acute toxicity from homebrewed gamma
hydroxybutyrate. J Am Board Fam Pract 1998;11(2):154-7. 4. John Mor g entha l e r and Dan Joy. Gamma - hydroxybutyrate. Smart drug
news. September 10th, 1994 [v3n6]. 5. Ta kaha r a J, Yunok i S, Ya kushi j i W, e t a l . Stimulatory effects of gamma-
hydroxybutyric acid on growth hormone and prolactin release in humans. J Clin Endocrinol Metab
1977;44(5):1014-7. 6. Laborit H. Sodium 4-hydroxybutyrate. Int J Neuropharmacol 1964;3:433-52. 7. Laborit H. Cor relations between protein and serotonin synthesis during
various activities of the central nervous system. Res Commun Chem Pathol Pharmacol 1972;3(1):51-81.
References 8. Vickers MD. Gamma-hydroxybutyric acid. Int Anesthesiol Clin 1969;7(1):75-
89. 9. Chin RL, Sporer KA, Cullison B, et al. Clinical course of gamma-
hydroxybutyrate overdose. Ann Emerg Med 1998;31(6):716-22. 10. Fadda F, Colombo G, Mosca E, et al. Suppression by g amma -hydroxybuty r
i c a c id of e thanol withdrawal syndrome in rats. Alcohol Alcohol 1989; 24(5):447-51.
11. Leikin JB, Paloucek FP. Poisoning & Toxicology Handbook, 2nd ed. Hudson, Ohio, Lexi-Comp Inc., 1995.
12. Baselt RC, Cravey RH. Disposition of Toxic drugs and Chemicals in Man, 4th ed. Foster City, CA, CTI, 1995.
13. Ejjenhorn MJ, Schonwald S, Ordog G, et al. Drug of Abuse. In Ejjenhorn MJ(ed):Ejjenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd ed. Baltimore, Williams and Wilkins, 1997.
14. Chin RL, Sporer KA, Cullison B, Dyer JE, Wu TD: Clinical course of GHB overdose. Ann Emerg Med June 1998;31:716-722.
15. David GEC, Fiona YC, Brian JB, Peter DF, Roger WB. Fatalities associated with theuse of GHB and its analogue in Australasia. MJA 2004;181(6):310-313.