Gamma-Hydroxybutyrate Toxicity Clinical Presentation

  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Mar 31, 2011
 

History

Patients with gamma-hydroxybutyric acid (GHB) toxicity typically present with altered mental status, making it difficult or impossible to obtain reliable history. The history may include agitation and confusion as well as myoclonus and seizurelike activity.

  • Prehospital personnel frequently have valuable information from the scene implicating GHB as the cause of the patient's complaint.
  • History may also be obtained from bystanders or friends since patients frequently ingest GHB in the presence of others at the gym, nightclubs, or parties.
  • History that the GHB was manufactured in a home lab is important since homemade GHB can be contaminated with sodium hydroxide (lye).
  • Patients given GHB surreptitiously as part of a drug-facilitated rape may have no history at all of drug ingestion.
  • Many patients present after taking multiple drugs, and efforts should be made to identify everything the patient has ingested.
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Physical

  • Neurologic findings: After GHB ingestion, the patient may have a period of euphoria that is rapidly followed by a period of profoundly depressed level of consciousness. This may progress to coma with a Glasgow Coma Scale of 3. GHB intoxication characteristically produces episodes of agitated delirium that can precede or follow the period of stupor or coma. Seizurelike movements and myoclonus are common during the course of the intoxication. These findings may reverse rapidly leaving the patient awake, alert, and oriented within minutes after several hours of altered mentation.
  • Cardiovascular findings: Bradycardia occurs in approximately 30-35% of ingestions. Hypotension occurs in approximately 10% of GHB ingestions and is usually mild. More profound cardiovascular changes can be seen in the presence of multidrug ingestions.
  • Pulmonary findings: Respiratory depression leading to frank apnea can occur and is exacerbated by multidrug ingestions. Decreased breath sounds or rales may indicate aspiration of gastric contents. Pulmonary edema is not a finding that is usually associated with GHB.
  • Gastrointestinal findings: Nausea and vomiting are common in GHB ingestions, especially during reemergence. Alkali burns to the lips, mouth, and GI tract can be seen when the GHB is contaminated by sodium hydroxide during the manufacturing process.
  • Constitutional: Mild hypothermia is a common finding in these cases.
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Causes

GHB is a common ingestion because it is easily manufactured and has several active precursors that have been available over the Internet. Its effects appeal to a variety of users.

  • Its euphoric effects make it a popular party drug.
  • Its reputation to increase growth hormone levels and muscle mass makes it popular with body builders.
  • Its rapid onset of action and formulation as a clear liquid make it popular in drug-facilitated rape.
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Contributor Information and Disclosures
Author

Theodore I Benzer, MD, PhD  Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Scott Cameron, MD  Consulting Staff, Department of Emergency Medicine, Regions Hospital

Scott Cameron, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Christopher Scott Russi, DO, FACEP  Assistant Professor of Emergency Medicine, Mayo Clinic

Christopher Scott Russi, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

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  10. Office of Applied Studies. Substance Abuse and Mental Health Services Administration Drug Abuse Warning Network 1992-1996. Unpublished Data. 1996.

  11. Rambourg-Schepens MO, Buffet M, Durak C, Mathieu-Nolf M. Gamma butyrolactone poisoning and its similarities to gamma hydroxybutyric acid: two case reports. Vet Hum Toxicol. Aug 1997;39(4):234-5. [Medline].

  12. Tancredi DN, Shannon MW. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 30-2003. A 21-year-old man with sudden alteration of mental status. N Engl J Med. Sep 25 2003;349(13):1267-75. [Medline].

  13. Zvosec DL, Smith SW. Agitation is common in gamma-hydroxybutyrate toxicity. Am J Emerg Med. May 2005;23(3):316-20. [Medline].

  14. Zvosec DL, Smith SW. Comment on "The abrupt cessation of therapeutically administered sodium oxybate (GHB) may cause withdrawal symptoms". J Toxicol Clin Toxicol. 2004;42(1):121-3; author reply 125-7. [Medline].

 
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