Rosen & Barkin's 5-Minute Emergency Medicine Consult (297 page)

Deliberate or accidental ingestion of GHB

DIAGNOSIS

• CNS:
  
  • CNS depression
    
  • Ataxia/dizziness
    
  • Impaired judgment
    
  • Aggressive behavior
    
  • Clonic movements of the extremities
    
  • Coma
    
  • Seizures
    
• Pulmonary:
  
  • Respiratory depression
    
  • Apnea
    
  • Laryngospasm (rare)
    
• GI:
  
  • Nausea
    
  • Vomiting
    
• Cardiovascular:
  
  • Bradycardia
    
  • Atrioventricular block
    
  • Hypotension
    
• Other:
  
  • Nystagmus
    
  • Hypothermia
    
• Withdrawal symptoms:
  
  • HTN
    
  • Tachycardia
    
  • Hyperthermia
    
  • Agitation
    
  • Diaphoresis
    
  • Tremors
    
  • Nausea, vomiting, and abdominal cramping
    
  • Hallucinations, delusions, and psychosis
    

• Diagnosis based on clinical presentation and an accurate history
  
• Exclude coingestants if signs and symptoms inconsistent with GHB intoxication
  

• Confirmatory GHB screen is typically a send-out lab and does not change ED management.
  
• Urine toxicology screen to exclude coingestants
  
• Serum alcohol level
  
• Urinalysis and creatine kinase (CK) if suspected rhabdomyolysis from prolonged immobilization or agitation
  

• ECG:
  
  • Sinus bradycardia
    
  • Atrioventricular block
    
• CXR:
  
  • Aspiration pneumonia
    
• Head CT if suspected occult head trauma
  

• Alcohol intoxication
  
• Barbiturate overdose
  
• Benzodiazepine overdose
  
• Neuroleptic overdose
  
• Opiate overdose
  
• Withdrawal:
  
  • Alcohol withdrawal
    
  • Sedative–hypnotic withdrawal
    

TREATMENT

Transport all pills/bottles and drug paraphernalia involved in overdose for identification in ED.

• ABCs:
  
  • Airway control essential
    
  • Administer supplemental oxygen
    
  • Intubate if indicated
    
• Administer thiamine, dextrose (or Accu-Chek), and naloxone for depressed mental status.
  

• Supportive care
  
• Bradycardia:
  
  • Atropine
    
  • Temporary pacing
    
• Hypotension:
  
  • 0.9% NS IV fluid bolus
    
  • Trendelenburg
    
  • Dopamine titrated to pressure
    
• Seizures:
  
  • Treat initially with benzodiazepine.
    
  • Treat refractory seizures with phenobarbital.
    
• Withdrawal:
  
  • Treat aggressively with benzodiazepine.
    
  • Treat with phenobarbital or propofol if large doses of benzodiazepines unsuccessful.
    

• Dextrose: 50–100 mL D
  ₅₀
  (peds: 2 mL/kg of D
  ₂₅
  over 1 min) IV; repeat if necessary
  
• Diazepam: 5–10 mg (peds: 0.2–0.5 mg/kg) IV q10–15min
  
• Dopamine: 2–20 μg/kg/min with titration to effect
  
• Lorazepam: 2–4 mg (peds: 0.03–0.05 mg/kg) IV q10–15min
  
• Naloxone: 0.4–2 mg (peds: 0.1 mg/kg; neonatal: 10–30 μg/kg) IV or IM
  
• Phenobarbital: 10–20 mg/kg IV (loading dose) monitor for respiratory depression with IV administration
  
• Propofol: 0.5–1 mg/kg IV (loading dose), then 5–50 μg/kg/min (maintenance dose)
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• Intubated patient
  
• Patient with hypothermia or other hemodynamic instability
  
• Coingestion prolonging duration of intoxication
  

• Asymptomatic after 6 hr of observation
  
• No clinical evidence of withdrawal syndrome
  

• Substance abuse referral for patients with recreational drug abuse.
  
• Patients with unintentional (accidental) poisoning require poison prevention counseling.
  
• Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation.
  

• Consider nontoxicologic causes for persistent altered mental status
  
• Routine hospital drug testing will not confirm GHB or other common recreational drugs of abuse
  

• Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), Rohypnol, and ketamine.
  Am Fam Physician
  . 2004;69(11):2619–2926.
  
• Schep LJ, Knudsen K, Slaughter RJ, et al. The clinical toxicology of γ-hydroxybutyrate, γ-butyrolactone and 1,4-butanediol.
  Clin Toxicol (Phila)
  . 2012;50(6):458–470.
  
• van Noorden MS, van Dongen LC, Zitman FG, et al. Gamma-hydroxybutyrate withdrawal syndrome: Dangerous but not well known.
  Gen Hosp Psychiatry
  . 2009;31(4):394–396.
  
• Wood DM, Brailsford AD, Dargan PI. Acute toxicity and withdrawal syndromes related to γ-hydroxybutyrate (GHB) and its analogues γ-butyrolactone (GBL) and 1,4-butanediol (1,4-BD).
  Drug Test Anal
  . 2011;3(7-8):417–425.
  
• Zvosec DL, Smith SW, Porrata T, et al. Case series of 226 γ-hydroxybutyrate-associated deaths: Lethal toxicity and trauma.
  Am J Emerg Med.
  2011;29(3):319–332.
  

CODES

968.4 Poisoning by other and unspecified general anesthetics

BASICS

• Chronic vasculitis of large- and medium-sized vessels that occurs among individuals over 50 yr of age
  
• Often referred to as temporal arteritis (TA)
  
• Median age of onset is 72
  
• Most commonly causes inflammation of arteries originating from the arch of the aorta
  
• Although usually clinically silent, involvement of the thoracic aorta occurs in a significant minority of patients, and aortic aneurysm or dissection may result
  
• Thoracic aortic aneurysm is a late manifestation with an incidence 17 times those without TA
  
• Abdominal aortic aneurysm is about twice as common in those with giant cell arteritis (GCA)
  
• Pathologic specimens feature patchy mononuclear granulomatous inflammation resulting in a markedly thickened intima and occlusion of the vessel lumen
  
• Occlusive arteritis may involve thrombosis of the ophthalmic artery resulting in anterior ischemic optic neuropathy (AION) and acute visual loss:
  
  • Visual symptoms are an ophthalmic emergency
    
• Inflammation of arteries supplying the muscles of mastication results in jaw claudication and tongue discomfort
  
• Age is the greatest risk factor:
  
  • Rare in patients <50 yr old
    
  • >90% are >60 yr old
    
  • Prevalence in individuals >50 yr is estimated at 1:500
    
• Increased prevalence in Northern latitude
  
• 2 to 4 times more common in women
  
• Rare in African American patients, common in Whites
  
• There is a strong association with polymyalgia rheumatica (PMR) ∼50%