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See related patient information handout on the dangers of gamma-hydroxybutyrate GHB usewritten by the authors of this article. Gamma-hydroxybutyrate GHB is an illicitly marketed substance that has recently gained popularity among body builders and party attendees as a drug of abuse.
GHB is a depressant that acts on the central nervous system. Because of its central nervous system depressant effects, GHB can be lethal when combined with alcohol or other depressants. Currently, there is no accepted medical use for GHB, and the U. Food and Drug Administration has prohibited its manufacture and sale. Clinicians should be familiar with the typical clinical presentation of GHB and its adverse effects. In addition, patients should be warned of its potential toxicity and be cautioned to avoid the use of GHB. Gamma-hydroxybutyrate GHB is a depressant that acts Where to get gamma-butyrolactone the central nervous system and has recently become a popular drug of abuse.
GHB is distributed illegally as a purported strength enhancer, euphoriant and aphrodisiac.
GHB is chemically related to gamma butyrolactone and 1,4 butanediol. The U. Food and Drug Administration FDA Where to get gamma-butyrolactone issued a warning to the public about these products because they have been linked to at least serious illnesses, 3 and as many as six deaths. A year-old man was brought to the emergency department by paramedics after being found lying prone and unresponsive on his patio. The initiating event was not witnessed, but his girlfriend reported that he had recently been using cocaine and other drugs, including GHB. The patient had no response to deep pain and his pupils were 2 mm in diameter, with a sluggish light reflex.
He was given intravenous naloxone and dextrose 50 percent solution with no response. On arrival at the emergency department, the patient remained unresponsive to voice or pain; his Glasgow Coma Scale score was 3. He was hypothermic with a rectal body temperature of Pupils, at this time, were 8 mm in diameter, with a sluggish light reflex bilaterally and he had no gag reflex. Bradycardia was Where to get gamma-butyrolactone on cardiac examination and bowel sounds were hypoactive. The remainder of the physical examination was unremarkable. The patient was administered a repeat dose of naloxone, 2 mg intravenously, with the minimal response of a brief episode of tachypnea.
The patient was then given lidocaine, mg intravenously; succinylcholine, mg intravenously; and pancuronium bromide, 15 mg intravenously, followed by endotracheal intubation. A nasogastric tube was placed. Stomach irrigation revealed a few pill fragments, and, subsequently, the patient was administered g of charcoal.
A Foley catheter was placed with return of clear yellow urine, which was sent for a toxicology analysis with a blood sample that had been ly drawn. The patient remained comatose and was transported to the computed tomographic CT scanner. Arterial blood gas measurements after intubation were as follows: pH, 7. Laboratory showed the following serum electrolyte levels: sodium, mEq per L; potassium, 4. Anion gap was 12 mEq per L; blood urea nitrogen, 12 mg per dL 4. The white blood cell count was 16, per mm 3 The CK-MB index was 2. Comprehensive urine and serum drug screens revealed only the presence of cocaine and opiates.
Subsequent urinalysis by gas chromatography revealed the presence of GHB. Serum ethanol level was zero. The electrocardiogram revealed a normal sinus rhythm with left axis deviation and diffuse ST-segment depression. The CT scan of the head showed no evidence of acute changes, and a chest radiograph was Where to get gamma-butyrolactone. The patient began to respond to verbal stimuli approximately two hours after arrival at the emergency department.
During the next hour, the patient became increasingly alert and returned to his normal mental status. The patient was admitted to the hospital and extubated on the day of admission. His hospital course, which included a psychiatric consultation, was uneventful, and the patient was discharged to a drug rehabilitation program.
GHB is Where to get gamma-butyrolactone relatively new drug of abuse, yet it has more than 30 common street names Table 1. Case reports in the past decade have demonstrated its potential for severe morbidity and death. In the past two years, at least six deaths have been attributed to GHB ingestion. With a little knowledge of chemistry, GHB can be easily synthesized from readily obtainable materials. Until recently, possession of GHB was not illegal under federal law.
GHB was first synthesized in as an alternative anesthetic to aid in surgery because of its ability to induce sleep and reversible coma.
However, it had little analgesic effect, and onset of coma was often associated with seizure Where to get gamma-butyrolactone including tonic-clonic jerking movements of the limbs or face. Inthe drug was banned by the FDA after several reports of adverse reactions in individuals using nutritional and weight loss supplements containing GHB. GHB's growing reputation as a euphoriant has contributed to its popularity as a recreational drug.
Although this rumor was never confirmed, it further stimulated street interest in the agent. Adverse effects related to GHB ingestion are highly variable among individuals Table 2. Users will typically experiment with GHB dosing to obtain the desired effects. This variability among users combined with the inherent variability in Where to get gamma-butyrolactone manufacturing, makes GHB a highly dangerous drug to consume.
Adverse effects typically occur within 15 minutes of ingestion of GHB. Respiratory depression; hypothermia; bradycardia with increases or decreases in blood pressure. Nystagmus; vertigo; ataxia; weakness; dizziness; sedation; confusion; hallucinations; short-term amnesia; coma, tonic-clonic seizure-like activity.
The management of GHB ingestion is primarily supportive, particularly if there is no reason to suspect a combination toxic exposure Table 3. Supportive management includes aspiration precautions and pulse oximetry. If concomitant ingestion is suspected, consideration should be given to gastric lavage and activated charcoal. In the case of isolated GHB ingestion, gastric lavage and activated charcoal are of limited value because the gastrointestinal absorption of GHB is rapid and small amounts of the drug are typically involved generally 1.
If concomitant ingestion is suspected, consider gastric lavage and activated charcoal. Conservative approach to intubation: use intubation only for severe respiratory depression, hypoxia or a combination toxic exposure. Without confirmatory evidence of GHB ingestion, the clinician must rule out other causes for the patient's altered mental status.
Physicians should be aware of the possible co-ingestion of other drugs or alcohol and treat these accordingly. In the presence of severe respiratory depression, hypoxia, or a combination toxic exposure, rapid sequence intubation is generally indicated for airway protection during lavage and during the treatment of hypoxia. However, a conservative approach to intubation is considered prudent, especially when the history of GHB ingestion is reliable.
In one study, 11 only eight out of 25 patients with a Glasgow Coma Scale score of 3 required intubation. Commonly used agents for reversal of coma have little or no use in the treatment of GHB ingestion. Further research is warranted before the use of these agents is recommended for GHB intoxication.
Despite the severity of altered mental status and the degree of support required to manage these patients, several case series have indicated that patients generally recover consciousness spontaneously. Patients who are extubated may be admitted to a regular hospital room and monitored. In selected cases, patients who are in stable condition and whose symptoms resolve may be discharged directly from the emergency department after a period of observation.
Although GHB use is reportedly highest among teenagers and young adults, its use cuts across all boundaries. The authors recommend that GHB use be discussed as part of the HES h ome life, e ducation, a ctivities, d rugs, s uicide, s ex assessment as well as the social history. When drug use is a concern, patients should be asked specifically about GHB use.
As always, appropriate counseling and Where to get gamma-butyrolactone consideration of referral to a rehabilitation program should be made. As with any other drug, the physician should inquire about multisubstance abuse. GHB is a potentially dangerous drug, associated with coma and seizure-like activity.
Physicians should be Where to get gamma-butyrolactone to the adverse effects of GHB because abuse may become more widespread as reports of its euphoric effects increase experimentation. In addition, health care professionals must be aware that despite FDA intervention, this substance is still available to and used by bodybuilders and party attendees.
As with any illicitly manufactured drug of abuse, the likelihood of adverse reactions is increased by the variance in purity and dosages taken. It is the physicians responsibility to educate the public about the dangers of this unusual recreational drug and report cases to poison control centers so that accurate statistical data may be collected regarding the prevalence of GHB use. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. JOHN J. Address correspondence to Ted O'Connell M. Reprints are not available from the authors. A tale of novel intoxication: seven cases of gamma-hydroxybutyric acid overdose.
Ann Emerg Med. Recreational drugs. Current trends in the 90s. Clin Lab Med. Food and Drug Administration. A tale of novel intoxication: a review of the effects of gamma-hydroxybutyric acid with recommendations for management. Toxic ingestion of gamma-hydroxybutyric acid.
South Med J. Pediatric gamma hydroxybutyrate intoxication. Acad Emerg Med. Gamma-hydroxybutyrate: an emerging drug of abuse that causes physical dependence. Vickers M. Gammahydroxybutyric acid. Int Anesthesiol Clin. Ross TM. Gamma hydroxybutyrate overdose: two cases illustrate the unique aspects of this dangerous recreational drug.
J Emerg Nurs. Where to get gamma-butyrolactone C. Coma-inducing drug GHB may be reclassified.Where to get gamma-butyrolactone
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Gamma-Hydroxybutyrate (GHB): A Newer Drug of Abuse