Gamma-Hydroxybutyrate Toxicity Workup

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

Laboratory Studies

  • Laboratory tests for gamma-hydroxybutyric acid (GHB) in serum or urine are not readily available. The diagnosis is made by history and physical examination. Reference laboratories can perform assays on blood and urine for GHB. These tests take time and are not useful clinically but can be very useful in legal cases (eg, drug-facilitated rape).
  • If the history is in question, a broad laboratory evaluation should be obtained to elucidate the cause of altered mental status. Complete blood count, serum electrolyte levels, liver function tests, toxicologic screens, ammonia level, arterial blood gas levels, osmolality, cultures, spinal fluid analysis, and pregnancy test may all be reasonable to obtain.
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Imaging Studies

  • Imaging will not help in making the diagnosis of GHB ingestion; however, brain imaging (CT or MRI) can be useful to rule out trauma or stroke.
  • Chest radiography is important to exclude aspiration pneumonitis.
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Other Tests

  • The electrocardiogram and cardiac monitoring are important. GHB ingestions can be associated with bradycardia. U waves are frequently seen on the ECG even in the absence of hypokalemia. Other co-ingestions may have severe cardiovascular consequences.
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Procedures

  • Lumbar puncture and spinal fluid analysis may be indicated if CNS infection is a concern.
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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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  2. 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].

  3. Wood DM, Nicolaou M, Dargan PI. Epidemiology of recreational drug toxicity in a nightclub environment. Subst Use Misuse. 2009;44(11):1495-502. [Medline].

  4. 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].

  5. 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].

  6. Chin MY, Kreutzer RA, Dyer JE. Acute poisoning from gamma-hydroxybutyrate in California. West J Med. Apr 1992;156(4):380-4. [Medline].

  7. 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].

  8. 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].

  9. 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].

  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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