Clinical Course of γ-Hydroxybutyrate Overdose.

STUDY OBJECTIVE: To describe the clinical characteristics and course of γ-hydroxybutyrate (GHB) overdose. METHODS: We assembled a retrospective series of all cases of GHB ingestion seen in an urban public-hospital emergency department and entered in a computerized database January 1993 through December 1996. From these cases we extracted demographic information, concurrent drug use, vital signs, Glasgow Coma Scale (GCS) score, laboratory values, and clinical course. RESULTS: Sixty-one (69%) of the 88 patients were male. The mean age was 28 years. Thirty-four cases (39%) involved coingestion of ethanol, and 25 (28%) involved coingestion of another drug, most commonly amphetamines. Twenty-five cases (28%) had a GCS score of 3, and 28 (33%) had scores ranging from 4 through 8. The mean time to regained consciousness from initial presentation among nonintubated patients with an initial GCS of 13 or less was 146 minutes (range, 16-389). Twenty-two patients (31%) had an initial temperature of 35°C or less. Thirty-two (36%) had asymptomatic bradycardia; in 29 of these cases, the initial GCS score was 8 or less. Ten patients (11%) presented with hypotension (systolic blood pressure≤90 mm Hg); 6 of these patients also demonstrated concurrent bradycardia. Arterial blood gases were measured in 30 patients; 21 had a Pco2 of 45 or greater, with pH ranging from 7.24 to 7.34, consistent with mild acute respiratory acidosis. Twenty-six patients (30%) had an episode of emesis; in 22 of these cases, the initial GCS was 8 or less. CONCLUSION: In our study population, patients who overdosed on GHB presented with a markedly decreased level of consciousness. Coingestion of ethanol or other drugs is common, as are bradycardia, hypothermia, respiratory acidosis, and emesis. Hypotension occurs occasionally. Patients typically regain consciousness spontaneously within 5 hours of the ingestion. [Chin RL, Sporer KA, Cullison B, Dyer JE, Wu TD: Clinical course of γ-hydroxybutyrate overdose. Ann Emerg Med June 1998;31: 716-722.].

Postexposure prophylaxis for HIV.

Health care workers are at risk for human immunodeficiency virus (HIV) and other infectious pathogens through exposure to blood and body fluids. Antiretroviral medications have been prescribed for postexposure prophylaxis following occupational exposure to the HIV since the early 1990s. This practice has since been extended to nonoccupational situations, such as sexual assaults. The efficacy of prophylactic therapy may be highly time-dependent and should be initiated as soon as possible. Wound care management and referral for social, medical, or advocacy services remain important for all cases.

Gamma-hydroxybutyrate serum levels and clinical syndrome after severe overdose.

STUDY OBJECTIVE: We discuss a prospective case series of patients who present with a severe gamma-hydroxybutyrate intoxication with confirmatory serum and urine gamma-hydroxybutyrate levels. METHODS: Patients with a clinical suspicion of gamma-hydroxybutyrate-like drug overdoses and a Glasgow Coma Scale score of 8 or lower were identified from July 1998 through January 1999. Serial serum specimens and a single urine specimen were collected. The levels of gamma-hydroxybutyrate were performed by gas chromatography-mass spectrometry. RESULTS: All 16 suspected severe gamma-hydroxybutyrate overdose patients had significant serum or urine levels of gamma-hydroxybutyrate. Serum levels ranged from 45 to 295 mg/L, with a median of 180 mg/L (interquartile range [IQR] 235 to 118 mg/L). Patients who developed a Glasgow Coma Scale score of 3 had serum levels that ranged from 72 to 300 mg/L, with a median of 193 mg/L (IQR 242 to 124 mg/L). The time of awakening ranged from 30 minutes to 190 minutes, with a median of 120 minutes (IQR 150 to 83 minutes). Quantitative serum gamma-hydroxybutyrate levels did not correlate with the degree of coma or the time to awakening. Urine levels ranged from 432 to 2,407 mg/L, with a median of 1,263 mg/L (IQR 1,550 to 796 mg/L). Mild transitory hypoventilation occurred in 5 of the 16 patients. CONCLUSION: All of our patients with clinically suspected severe gamma-hydroxybutyrate overdose were confirmed to have significant serum and urine levels of exogenous gamma-hydroxybutyrate. They presented with severe coma that lasted 1 to 2 hours. Transient hypoventilation occurred in one third of these patients.

Emergency management of infectious diseases

This book explores the epistemological and ethical issues at the foundations of environmental philosophy , emphasising the conservation of biodiversity . Sahota Sarkar criticises attempts to attribute intrinsic value to nature and defends an anthropocentric position on biodiversity conservation based on an untraditional concept of transformative value. Unlike other studies in the field of environmental philosophy , this book is as much concerned with epistemological issues as with environmental ethics. It covers a broad range of topics, including problems of explanation and prediction in traditional ecology and how individual-based models and Geographic Information Systems (GIS) technology is transforming ecology. Introducing a brief history of conservation biology, Sarkar analyses the consensus framework for conservation planning through adaptive management. He concludes with a discussion of directions for theoretical research in conservation biology and environmental philosophy