A Collapsed Giant

Dr. Jacky Sia

RHAED

TSKAED 1998 No computer system No Toxicology database No CMS No internet No urinary test.

Case summary 39-year Caucasian. 240 lbs giant. Well along Collapsed and

convulsion in gym.

DDx of collapse

Reading!

Possible supplement EFA: ephedrine, caffeine, aspirin. EFT: Ephedrine, Foskolin, Theophylline. Creatine. Steroids: oral, injectable. Herbal extract. Thyroid extract. Many more….

Drugs before gym

another 260-lbs giant.

History

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.

GHB poisoning

Media interview

Male - not exemption

Layman Diagnostic kit

Layman Diagnostic kit

History 1980s: over-the-counter in health

stores. Abused as recreational drugs. 1991: ? Political reason. Banned for its

excellent GA property.

GHB - naturally found Hypothalamus Basal ganglia Kidney Heart Skeletal Brown fat tissue.

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

GHB – Recovery Time

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.

Therapeutic Value Sleeping disorder Narcolepsy Alcohol withdrawal Depression

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 1

Age 23 man

GCS 3

Temp 35.8

RR No

Toxi screen BZ

ET +

Withdraw 30 min., agitation

Case series 2

Age 20 man

GCS 3

Temp 35.8

RR Labour

Toxi screen Alcohol

ET +

Withdraw 1 hr., agitation

Case series 3

Age 20 lady

GCS 3

Temp UK

RR No

Toxi screen BZ, Cocaine

ET +

Withdraw 4 hours

Case series 4

Age 20 lady

GCS 3

Temp 34.6

RR 8 / min

Toxi screen -ve

ET +

Withdraw 3 hours.

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

? Toxidrome

National laboratories

Lab tests not readily available. LOC: serum level 50 mg/dL. Coma: serum level 260 mg/dL.

Drugs Combinations!

Lessons

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.