Gamma-Hydroxybutyrate Toxicity Treatment & Management
- Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD more...
Prehospital Care
- Prehospital personnel can be invaluable by obtaining a history of ingestion from the patient, friends, and/or bystanders and securing evidence of potential GHB ingestion (eg, small shampoo bottles).
- Prehospital care is supportive. Airway, breathing, and circulatory support are the primary goals. Oxygen should be given. The airway should be maintained with either positioning, nasal or oral airway, or endotracheal intubation if airway reflexes are compromised. Observe cervical spine precautions if there is a risk of trauma.
- Intravenous access and fluids are useful for hypotension. Cardiac monitoring should be performed for all patients with altered mental status.
- As for all patients presenting with altered mental status, rapid glucose determination or 50 mL of D50W, thiamine 100 mg IV, and naloxone IV should be considered. Naloxone has little use in GHB ingestions, but opioid co-ingestions are common. Clinicians should be aware that an administration of naloxone can precipitate opioid withdrawal in chronic opioid users resulting in vomiting. In patients who are unconscious due to GHB exposure and are unable to protect their airway, this can result in aspiration of gastric contents and an increase in morbidity/mortality.
Emergency Department Care
ED management in GHB overdose is primarily supportive. No specific antidotes exist for GHB. The course of GHB ingestion may be short lived with rapid recovery. Therefore, many of these patients can be discharged from the emergency department without admission to the hospital.
- Airway patency and aspiration precautions are of paramount importance. Usually respiratory drive and protective airway reflexes are preserved, but if either are compromised, the patient should be intubated. Co-ingestions increase the risk of respiratory compromise. Prior to intubation, sedation may not be necessary if the patient is in a coma. Neuromuscular blockade should be used to avert the combativeness and agitation that can be seen in GHB ingestions.
- Consider activated charcoal if co-ingestion is suspected. Gastric lavage would be indicated only if a lethal dose of another drug (acetaminophen, tricyclic antidepressant) had occurred within 1 hour of presentation. Endotracheal intubation should precede gastric lavage to prevent aspiration. Clinicians should be aware that endotracheal intubation does not completely prevent aspiration of the charcoal.
- Cardiac monitoring is indicated. Bradycardia is common, and other dysrhythmias have been seen.
- A thorough examination of the oropharynx should be performed. Mucosal burns can occur when the GHB ingested is contaminated with sodium hydroxide from the manufacturing process.
- If the patient has severe respiratory compromise or a complicated ingestion or if the diagnosis is in question, the patient should be admitted to the hospital for further evaluation and treatment.
Consultations
- The regional poison control center can provide valuable information, especially in complex ingestions.
- Otolaryngology or gastrointestinal consultation may be needed if evidence of alkali burns to the oropharynx or GI tract is present.
- A psychiatrist should be consulted for patients who are suicidal or depressed prior to discharge.
Dyer JE, Roth B, Hyma BA. Gamma-hydroxybutyrate withdrawal syndrome. Ann Emerg Med. Feb 2001;37(2):147-53. [Medline].
Anderson IB, Kim SY, Dyer JE, et al. Trends in gamma-hydroxybutyrate (GHB) and related drug intoxication: 1999 to 2003. Ann Emerg Med. Feb 2006;47(2):177-83. [Medline].
Wood DM, Nicolaou M, Dargan PI. Epidemiology of recreational drug toxicity in a nightclub environment. Subst Use Misuse. 2009;44(11):1495-502. [Medline].
Traub SJ, Nelson LS, Hoffman RS. Physostigmine as a treatment for gamma-hydroxybutyrate toxicity: a review. J Toxicol Clin Toxicol. 2002;40(6):781-7. [Medline].
CDC. From the Centers for Disease Control and Prevention. Gamma hydroxy butyrate use--New York and Texas, 1995-1996. JAMA. May 21 1997;277(19):1511. [Medline].
Chin MY, Kreutzer RA, Dyer JE. Acute poisoning from gamma-hydroxybutyrate in California. West J Med. Apr 1992;156(4):380-4. [Medline].
Chin RL, Sporer KA, Cullison B, Dyer JE, Wu TD. Clinical course of gamma-hydroxybutyrate overdose. Ann Emerg Med. Jun 1998;31(6):716-22. [Medline].
Li J, Stokes SA, Woeckener A. A tale of novel intoxication: a review of the effects of gamma-hydroxybutyric acid with recommendations for management. Ann Emerg Med. Jun 1998;31(6):729-36. [Medline].
Li J, Stokes SA, Woeckener A. A tale of novel intoxication: seven cases of gamma-hydroxybutyric acid overdose. Ann Emerg Med. Jun 1998;31(6):723-8. [Medline].
Office of Applied Studies. Substance Abuse and Mental Health Services Administration Drug Abuse Warning Network 1992-1996. Unpublished Data. 1996.
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].
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].
Zvosec DL, Smith SW. Agitation is common in gamma-hydroxybutyrate toxicity. Am J Emerg Med. May 2005;23(3):316-20. [Medline].
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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