A tale of novel intoxication:: Seven cases of γ-hydroxybutyric acid overdose

Study objective: We describe seven patients presenting with combination substance abuse involving gamma-hydroxybutyric acid (GHB). Methods: 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. Results: 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. Conclusion: Emergency physicians should be alerted to this agent, its characteristic effects, and its potential for serious sequelae including respiratory arrest and death.