Gamma-Hydroxybutyrate Toxicity Follow-up

• Patients with gamma-hydroxybutyric acid (GHB) poisoning who are in stable condition with symptoms that have completely resolved may be released from the ED in the care of responsible person after 6 hours of observation.
• Patients with significant co-ingestions, those who have been intubated, and those with symptoms that persist after 6 hours should be admitted to a monitored bed.
• Admit patients with severe symptoms or evidence of hemodynamic compromise to an intensive care unit.
• Patients who have ingested GHB as a suicide attempt should be evaluated by a psychiatrist after the intoxication has resolved to determine if they need inpatient psychiatric care.
• If there is suspicion that patient was sexually assaulted, appropriate services (social work, police, obstetrician/gynecologist) should be involved in the patient's evaluation and treatment.
• Patients who have ingested the GHB precursor, 1,4 butanediol (BD), may have a prolonged clinical course. The BD is converted to GHB by the enzymes alcohol dehydrogenase and aldehyde dehydrogenase. If the patient presents with ethanol and BD ingestion, an initial period of depressed mental status can occur followed by clearing, as the ETOH is metabolized. Then, the BD is metabolized to GHB, and a second period of lethargy or coma ensues. These patients require a prolonged period of observation.

• Transfer should only be necessary if the patient requires intubation and no ICU level of care exists at the facility.

• Recent studies have shown a decrease in the incidence of GHB intoxications. Public health measures to inform young people of the risks of GHB and governmental restrictions on the sale of GHB and its precursors (GBL and BD) have been helpful in promoting this decrease.

Complications of GHB toxicity may include the following:

• Coma
• Respiratory depression
• Bradycardia
• Hypotension
• Hypothermia
• Vomiting and aspiration of gastric contents and activated charcoal
• Death

• Patients with an isolated instance of GHB ingestion generally have a good prognosis.
• Patients who have been taking large doses of GHB for an extended period of time may develop a withdrawal syndrome characterized by a severely agitated delirium requiring restraints. The withdrawal may be prolonged, lasting 5-15 days and associated with visual and auditory hallucinations. Most patients have been taking frequent doses every 1-3 hours around the clock. The withdrawal starts 1-6 hours after the last dose. This withdrawal syndrome requires acute hospitalization.

• Many patients with GHB toxicity mistakenly believe (or claim to have been led to believe) that GHB is a legal substance. Educate these patients about the illegality of GHB manufacture and distribution as well as the potential complications caused by GHB use.
• Many patients intubated for severe respiratory depression and hypoxemia spontaneously awaken with no recollection of their brush with mortality. Many refuse to believe that their prior condition was potentially lethal, despite any evidence to the contrary; this may make patient education quite difficult and contribute to recidivism.
• The use of GHB as a date rape drug necessitates a more thorough workup and dispositional plan than most other ingestions. Date rape victims should receive proper and prompt forensic and medical examination, sexually transmitted disease (STD) prophylaxis, pregnancy counseling, psychological or other support counseling, and follow-up.
• Those patients who have used GHB in an attempt to increase growth hormone levels and enhance a bodybuilding program need to be made aware that no evidence for its effectiveness exists. They need to learn the very real dangers of GHB use.
• For excellent patient education resources, visit eMedicine's Poisoning - First Aid and Emergency Center, Mental Health and Behavior Center, and Substance Abuse Center. Also, see eMedicine's patient education articles Club Drugs, Drug Dependence & Abuse, Poisoning, and Activated Charcoal.