Grievous Bodily Harm

• Gamma hydroxybutytric acid
• CNS depressant that’s abused for its ability to induce euphoria, hypnosis, and amnesia.
  • Crosses blood-brain barrier
  • Toxicity occurs from depressant effects
• Presentation:
  • Colourless
  • Odourless
  • Bitter tasting liquid (but can also be powder)

• Popular at rave parties for euphoric effects
• Bodybuilder Supplement (growth hormone)
• Sleep Aid
• Tried as an anaesthetic agent
• Used as date rape drug
• Tried as a therapy for narcolepsy and alcohol withdrawal

• GBH (grievous bodily harm)
• Liquid ecstasy
• Fantasy
• Cherry Meth
• G
• Georgia home boy
• Goop
• Salty water
• Scoob

(SCGH Alcohol & Drug Liaison Project )

Cardiovascular:

• Bradycardia
• Hypertension/ Hypotension
• ECG Changes

Respiratory:

• Depression
• Apnoea
• Cheyne-stokes
• Aspiration

Gastrointestinal:

• Nausea
• Vomiting
• Caustic Burns

Neurological:

• CNS depression
• Coma
• Myoclonus
• Seizures
• Miosis
• Ataxia
• Agitation
• Euphoria
• Amnesia

Metabolic:

• Respiratory Acidosis
• Metabolic Acidosis
• Hyperglycaemia
• Hypokalaemia
• Hypernatreamia

The GHB Clinical Syndrome generally presents with coma, respiratory depression, mild bradycardia, and vomiting

1. CNS depression
2. Nystagmus
3. Respiratory depression
4. Miosis
5. Myoclonus
6. Vomiting

Many other situations can precipitate patient presentations with coma, seizures, respiratory depression and respiratory arrest including:

• Hypoglycaemia
• Opiate overdose
• Ketamine overdose
• Subarachnoid Haemorrhage (SAH)
• Cerebrovascular Accident (CVA)
• CNS Lesion
• Infection

Airway:

1. May need adjunct
2. Position on Side
3. Can require RSI

Breathing:

1. Require monitoring RR & Spo2, Co2

Circulation:

1. Tx: bradycardia with atropine
2. Hypotension responds fluid challenge

Disability:

1. Can be combative, need restraints, ?sedation
2. Decreasing GCS = Intubate

Exposure:

1. Other drugs on board (commonly ETOH, Amphetamines)
2. Other toxidromes

Toxicological Screen:

1. 12 lead ECG
2. BSL
3. Paracetamol level
4. Temperature
5. Blood alcohol level

Decontamination:

• Activated  Charcol not clinically useful as onset CNS depression  occurs rapidly

Enhanced Elimination:

• Not clinically useful

Antidotes:

• Physostigmine has been used and proposed as antidote for GHB
• Poor safety profile in GHB
• Good supportive care should deliver same outcome.

• Maximal toxicity is usually evident by the time pt arrives in ED
• Generally have a short clinical course with recovery to GCS 15 within 6 hours
• Prolonged recovery over 6 hours requires further investigation or pt intoxicated with another adjunct
• Patients have been reported to frequently self extubate

Prehospital Presentations:

• Victorian study looked @ ambulance  related attendances for GHB Vs Heroin
• Retrospective analysis from Mar 01- Oct 05.
• 618  attendances for GHB vs 3723 for Heroin
• 256 had GHB and other drugs on board
• Majority under 25, and had GCS <10
• 90% of GHB patients transported to hospital compared to 21% for heroin.

Dietze PM, Cvetkovski S, Barratt MJ, Clemens S, Patterns and incidences of y-Hydroxybutyrate (GHB)-related ambulance attendances in Melbourne, Med J Aust. 2008 Jun 16;188(12):709-11. PMID: 18558893

Presentations to ED

• Summary:
  • GHB attendances are of high acuity, with decreased GCS and potential airway threats.
  • With close conservative management, most recover quickly without adverse sequelae.
  • Patients generally made rapid recovery in GCS with overall medium LOS of 199 minutes
• 30 month study of GHB related presentations to St Vincent’s ED (NSW) 2002-2005
• 170 patients attendances
• Highest attendance on weekends & Public Holidays, between 0400-0800.
• GHB was ingested alone in 62 cases
• 52% triaged as ATS 1
• 54% had GCS OF 3-8/15
• 8% required airway support with endotracheal intubation

Munir VL, Hutton JE, Harney JP, Buykx P, Weiland TJ, Dent AW. Gamma-hydroxybutyrate: a 30 month emergency department review. Emerg Med Australas. 2008 Dec;20(6):521-30. PMID: 19125832

Mortality:

• Australasia study Jan 2000 – Aug 2003.
• 10 confirmed GHB Deaths
• Average age 29.8 years
• 8 males,2 females
• Most common cause of death respiratory arrest

Caldicott DG, Chow FY, Burns BJ, Felgate PD, Byard RW. Fatalities associated with the use of gamma-hydroxybutyrate and its analogues in Australasia. Med J Aust. 2004 Sep 20;181(6):310-3. PMID: 15377240

• 2 cases of GHB intoxication in children related to ingestion of Bindeez Balls.
• Samples taken of the toy beeds were positive for 1,4-butanediol, which is metabolised  to GHB in humans.
• Both presented with altered conscious states that improved quickly.
• Urine drug screens positive for GHB
• International recall of product demonstrated other cases worldwide

Patient 1:

• 2 year old male previously well
• Presents with fluctuating GCS 7-12/15
• Bradycardia/ hypotensive
• Tx: for encephalitis/ postictal state
• Marked clinical improvement after few hours
• Urine drug screen positive on day 5 for GHB

Patient 2:

• 10 year old girl
• Presented with 4 min generalised seizure, post vomiting up 100 Bindeez balls.
• Had further 7 episodes of vomiting
• Remained drowsy GCS 14/15 for 5 hours then made full recovery
• Urine drug screen, and balls positive for GHB

Gunja N, Doyle E, Carpenter K, Chan OT, Gilmore S, Browne G, Graudins A. Epub 2007 Nov 19. Gamma-hydroxybutyrate poisoning from toy beads. Med J Aust. 2008 Jan 7;188(1):54-5. PMID: 18021061

• GHB is highly addictive
• Need frequent ingestions to WD

Symptoms of withdrawal:

• Very similar to ETOH WD
• Insomnia, anxiety, nausea, vomiting
• Tremulousness, hallucinations, disorientation, agitation
• Can manifest 1-6hours post last dose in chronic user
• Delirium can last up to 2 weeks
• Hyperthermia and rhabdomylysis can occur

Withdrawal Management:

• Supportive Care
• Benzodiazepines (Diazepam)
• Phenothiazines (Olanzapine)

Drink spiking!!

• Has been implicated as date rape drug!
• Limited literature to support this

Disaster Preparedness:

• Multiple pts presenting in short period of time
• Often present 0400-0800 (decreased staffing)
• Need for multiple ventilators
• Need to call in staff
• Arrange ICU beds

Is it in Western Australia?

• We tend to be the virgin state.
• Popular on the east coast of Australia during rave’s
• Popular in the media
• Limited cases known in WA
• More raves/festivals each year in Perth could start to see it