Where Myth meets Fantasy Dr Laura Martin Registrar Department of Emergency Medicine

0530 ambulance communication... 8 minutes until arrival at ED 2 female patients mid twenties found unconscious outside a nightclub on K road both status 2 (unstable) patient A: GCS 5, P110, BP 96/64 patient B: GCS 7, P100, BP110/68

On arrival in ED Collateral History from male companion both women had attended a dance party ingested minimal alcohol ingested a “clear liquid” 30min prior to collapsing no other medical history available

Patient A Primary survey airway patent, placed in a hard collar respiration rate 10/min good breath sounds bilaterally SpO2 100% on 6L/min HR 108 BP 98/70 well perfused peripheries GCS 6/15 (E1 V1 M4) PERL 5mm

Secondary Survey “Glitter sign” positive Odour of ethanol T 35.6oC Abrasion and haematoma left supraorbital ridge No other evidence of trauma Rest of examination was unremarkable BM glucose normal

Management 0.9% NaCl 1000ml I.V stat Standard rapid sequence induction and intubation Ventilation Ongoing sedation and paralysis

Investigations FBC, U&E’s normal ABG unremarkable ECG sinus tachycardia QTc 0.38s Ethanol 12 mmol/L Paracetamol/salicylate levels negative CXR no evidence of aspiration CT head normal C-spine X-rays normal

Disposition Uneventful DCCM admission and early extubation Self Discharged

Patient B Primary Survey Patent airway Respiratory rate14 bpm normal breath sounds HR 100, BP 110/74 GCS 8/15 (E1 V2 M5) PERL 6mm

Secondary Survey T 36.9o C no evidence of trauma during initial assessment roused rapidly to a GCS 14 (E4 V4 M6) rest of examination was unremarkable BM glucose normal

Disposition After a 4-hour, uneventful, observation period the patient was discharged to the care of her family

The Offending Agent Gamma hydroxybutyrate 1,4-Butanediol GHB GBH Fantasy 1,4-Butanediol one 4 B Gamma butyrolactone GBL liquid G

GHB Naturally occurring Neuromodulator Dopaminergic GABA Endogenous opioids

The Facts of Fantasy Initial excitation Amnesia increasing sedation Gait ataxia Nausea/vomiting “Seizure-like” activity Coma Respiratory depression Reduced cardiac output

The Magic Of Fantasy Euphoria Disinhibition Enhancement of libido Heightened sexual performance Prolonged erection Sensitivity to touch Enhanced interpersonal communication

The Myth of Fantasy Steep dose response curve Inter-individual variability Impurity of street preparations Misinformation Implicated in date-rape

Fantasy: ED issues Intubation? Investigation? Decontamination? Physostigmine Resource issues

References NEJM Vol. 344, No.2 Jan 11, 2001 p87 Ann Emerg Med 37:1 Jan 2001 Annal Emerg Med 31:6 June 1998 p717 J of Emerg Med 18:1 Jan 1999 Emerg Med Clinics N America 18:4 Nov 2000 BMJ 314:35 Jan 4 1997 Addiction 92:1 1997 p89

GHB Presentations

Disposition of Patients 59 clinical cases 65.5% Discharged from ED 19.3% Admitted 15.2% Self Discharged

Controversies revisited Conservative management of the unconscious GHB patient Value of Physostigmine Duration of monitoring Prevention Toxicological screening