Rachel L. Chin

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.].

Development of Ventricular Fibrillation After Intravenous Calcium Chloride Administration in a Patient With Supraventricular Tachycardia

The i.v. administration of calcium before or shortly after treatment of supraventricular tachycardia with verapamil has been suggested to counteract a hypotensive response to verapamil. We discuss the case of a patient who presented to the emergency department with an accelerated wide-complex tachycardia and minimal symptoms. Immediately after i.v. administration, of 1 g calcium chloride as pretreatment for verapamil administration, ventricular fibrillation developed. Emergency physicians should be aware of potential dangers after the administration of i.v. calcium preparations when trying to prevent known hypotensive side effects of i.v. verapamil administration.

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.

HIV in the emergency department. Preface.

Worldwide, an estimated 33 million people are living with human immunodeficiency virus (HIV) infection and 2.7 million people are newly infected yearly. In 2006, an estimated 1.1 million people were living with HIV infection in the United States. About 21% of these patients remained undiagnosed. In 2008, an estimated 56,300 people were newly infected with HIV in the United States. As these data suggest, the epidemic clearly continues. As a result, emergency physicians worldwide face the challenge of caring for HIV-infected patients on a daily basis. Whether working in an inner city, suburban, or rural hospital, emergency physicians must maintain a basic knowledge of the medically complex and diverse disease processes that can affect this group of patients. Before the mid 1990s, HIV-infected patients typically presented to the emergency department (ED) as young, previously healthy individuals suffering from the devastating effects of opportunistic infections and full-blown AIDS. There remained a relatively small number of illnesses that HIV-infected patients experienced and a limited knowledge of their therapies. Most opportunistic infections proved fatal within a short period. In stark contrast, recent years have shown the success of antiretroviral therapy (ART), as HIV-infected patients now present with a wide range of medical issues, many of them chronic in nature. ART has enabled these patients to live longer and experience fewer opportunistic complications while simultaneously uncovering a myriad of previously unknown comorbidities related to both the disease and its therapies. Research and clinical experience have revealed a wealth of information about the shortand long-term effects of the disease itself. From the elusive characteristics of acute HIV infection, to the more clinically obvious long-term sequelae of HIV, including nephropathy and coronary artery disease, HIV-infected patients have become a complex subset of the ED population. ARTs themselves have been shown to cause multiple complications such as insulin resistance, the metabolic syndrome, immune reconstitution inflammatory syndrome (IRIS), hepatic steatosis, and lactic acidosis. Given the multitude of recent advances and ongoing research in the area of HIV/AIDS, keeping up with this topic is no small task.