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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. Disposition Uneventful DCCM admission and early extubation
Self Discharged

9. 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

10. 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

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

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

14. GHB Naturally occurring Neuromodulator Dopaminergic GABA
Endogenous opioids

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

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

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

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

19. 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 Addiction 92: p89

20. GHB Presentations

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

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