This week’s case was a tough one, but thought it would be a good chance to throw in the possible drug overdoses into one case.  I myself had to look a lot of these up so which helps me remember them.  I hope it will be the same for you.  In any case, here was the question:

 

A 19-year-old man is brought to the ED by EMS after he was found lying on the floor at a dance club. EMS states that the patient seemed unconscious at the dance club but as soon as they transferred him onto the gurney he became combative. Upon arrival in the ED, his blood pressure is 120/65 mm Hg, heart rate is 75 beats per minute, temperature is 98.9°F, respiratory rate is 12 breaths per minute, and oxygen saturation is 98% on room air. On physical exam, his pupils are mid-sized, equal and reactive to light. His skin is warm and dry. Lung, cardiac, and abdominal exam are unremarkable. As you walk away from the bedside, you here the monitor alarm signaling zero respirations and the oxygen saturation starts to drop. You perform a sternal rub and the patient sits up in bed and starts yelling at you. As you leave him for the second time, you hear the monitor alarm again signal zero respirations. You administer naloxone, but there is no change in his condition. Which of the following is most likely the substance ingested by this patient?

 

1)     GHB

2)     Diazepam

3)     Cocaine

4)     PCP

5)     Heroin

 

While this was a difficult question, the answer was GHB (a natural neurotransmitter that induces sleep). So, first things first, this is a big recreational drug, but has also been sold as a muscle builder (release of growth hormone), a diet aid, and a sleep aid. It is also being used as a date rape drug.  A quick visual/war story: I once found one of my bartenders unconscious in a porta-potty naked because he had overdosed on GHB (try forgetting that visual). 

 

Patients with GHB overdose generally have a decreased level of consciousness. In contrast to other sedative/hypnotic overdoses, the level of consciousness tends to FLUCTUATE quickly between agitation and depression. A distinctive feature of GHB intoxication is respiratory depression with apnea, interrupted by periods of agitation and combativeness, especially following attempts at intubation.

(b) Diazepam, a benzodiazepine, also depresses mental and respiratory function but typically patients REMAIN sedate. (c) Cocaine is a stimulant that increases heart rate, blood pressure, and usually causes the pupils to dilate. (d) PCP intoxication may cause bizarre behavior, lethargy, agitation, confusion, or violence. (e) Heroin intoxication can cause respiratory depression. Patients usually present with miotic pupils.

 

Best to treat serious GHB overdoses with lorazepam with physostigmine (alternatively you can treat with neostigmine or physostigmine alone)