A tale of novel intoxication: seven cases of gamma-hydroxybutyric acid overdose.

Abstract

We describe seven patients presenting with combination substance abuse involving gamma-hydroxybutyric acid (GHB). During a 3 month period, we identified consecutive patients with GHB ingestion confirmed by urine mass spectrometry presenting to a high-volume urban emergency department. All patients presented with acute delirium and transient but severe respiratory depression. With supportive care, including intubation and mechanical ventilation in four cases, normal mentation and respiratory function returned within 2 to 6 hours. None of these patients had documented seizures, and none of the four patients who received naloxone had a reversal response. This clinical observation supports previous experimental work in GHB-intoxicated human subjects demonstrating neither epileptiform changes on electroencephalography nor reversal with naloxone. Two findings are remarkable in this series. The first is the observation of a peculiar state of violent aggression present on stimulation of the GHB-intoxicated patient despite near or total apnea. The fact that patients fully recovered from this state may be the result of a previously demonstrated GHB hypoxia-sparing effect. The second is the observation of ECG abnormalities in several cases, including U waves in five patients. Emergency physicians should be alerted to this agent, its characteristic effects, and its potential for serious sequelae including respiratory arrest and death.