Case #7: A Bad Drink
Author: Michael Gottlieb, MD
Peer Reviewer: Steve Aks, MD
A 19 year old female is brought to the ED by her friends after she suddenly passed out at a party. She has no past medical history, does not take any medications, and felt fine prior to losing consciousness, with no prodromal symptoms. On examination there is no evident trauma and her pupils are equal, round, and reactive. The remainder of her exam is non-focal.
Vitals: Temp: 98.0, HR: 74, RR: 8, BP: 108/74, O2 sat: 93% on RA
The patient was intubated secondary to concern for airway protection. Two hours later, she is wide awake and is rapidly extubated.
What is the most likely toxicologic etiology of this patient’s presentation?
Altered mental status carries a broad differential. However, given her history of previously feeling normal and the temporal relationship to the party, illicit drugs should be high on the differential. The most common of these are γ-hydroxybutyrate (GHB), rohypnol (‘Roofies’), benzodiazepines (BZDs), ethanol, and ketamine. In this case, the very rapid return of consciousness would make GHB the most likely culprit.
If GHB is the responsible drug, what other clinical symptoms might you expect to see with this patient?
CNS dysfunction is the most common symptom complex. At low doses, patients develop amnesia and sedation. Higher doses lead to delirium, loss of consciousness, respiratory depression (without hypoxia), and coma. These patients tend to be combative when aroused. Bradycardia, hypotension, hypothermia, and seizure-like activity are rare symptoms.
What further work-up is required?
Consider Serum ASA, APAP, and ethanol levels if the etiology is unclear. Although serum GHB levels are available, they are rarely helpful, as GHB has a very short half-life and all humans have variable baseline GHB levels present in their blood. It is also important to consider the potential concomitant suicide attempt or sexual assault with the inclusion of any pertinent evaluation for each of these scenarios.
What is the disposition of these patients?
Given the short serum half-life, patients may be discharged when clinically improved, as long as the patient does not require further evaluation for suicidality or sexual assault. Most patients fully regain consciousness in 6 hours, at which time discharge is appropriate. If after 6 hours status is unchanged, consider admission to ICU for continued monitoring.
References:
Drasbek KR, Christensen J, Jensen K. Gamma-hydroxybutyrate—a drug of abuse. Acta Neurol Scand. 2006 Sep;114(3):145-56.
Li J, Stokes SA, Woeckener A. A tale of novel intoxication: seven cases of gamma-hydroxybutyric acid overdose. Ann Emerg Med. 1998 Jun;31(6):723-8.
Li J, Stokes SA, Woeckener A. A tale of novel intoxication: a review of the effects of -hydroxybutyric acid with recommendations for management. Ann Emerg Med. 1998 Jun;31(6):729-36.
Mason PE, Kerns WP 2nd. Gamma hydroxybutyric acid (GHB) intoxication. Acad Emerg Med. 2002 Jul;9(7):730-9.
Zvosec DL, Smith SW, Porrata T, et al. Case series of 226 γ-hydroxybutyrate-associated deaths: lethal toxicity and trauma. Am J Emerg Med. 2011 Mar;29(3):319-32.
Return to Case List
