Correspondence
Brigham and Women’s Hospital/Harvard Medical School
Boston, MA
doi:10.1016/j.annemergmed.2006.03.039
1. Kwan I, Bunn F, Roberts I, on behalf of the WHO Pre-Hospital
Trauma Care Steering Committee. Spinal immobilisation for trauma
patients (Cochrane Review). In: The Cochrane Library, Issue 1,
2005. Chichester, UK: John Wiley & Sons, Ltd.
2. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course
of missed spine fractures. J Trauma. 1987;27:980-986.
3. Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missed
cervical spine injuries. J Trauma. 1993;34:342-346.
4. Kaups KL, Davis JW. Patients with gunshot wounds to the head do
not require cervical spine immobilization and evaluation. J Trauma.
1998;44:865-7.
Response to: Out-of-Hospital Pediatric Cardiac
Arrest: An Epidemiologic Review and Assessment
of Current Knowledge
To the Editor:
I read with interest the well-done epidemiologic review of
pediatric cardiac arrest by Donoghue, Nadkarni, Berg et al.1 I
am writing to expand upon their discussion of patients who
achieve return of spontaneous circulation through bystander
CPR alone. Although data on this group is limited, it is not
absent. Sirbaugh et al2 described 41 such children in their
prospective, population-based epidemiologic study of pediatric
cardiac arrest. All of these children were submersion victims and
all survived (compared with only 6 survivors from 300 children
still in arrest upon EMS arrival).2 This suggests that CPR is
performed more commonly than accounted for in those studies
that enroll only patients still in arrest upon EMS arrival. It also
suggests that bystander CPR alone may be sufficient to rescue a
significant portion of cardiac arrest victims. Donoghue et al
rightly points out that it is difficult to determine if patients
resuscitated by bystander CPR alone were truly in cardiac
arrest.1 Some insight into this issue can be gained by examining
the “bystander saves” that my colleagues and I included in a
study of out-of-hospital CPR published in this journal in 1995.3
We included children who were resuscitated by bystanders prior
to EMS arrival if they had documented acidosis or continued
alteration in mental status upon arrival to the ED. We described
11 such patients from a total of 56 patients receiving CPR in
the out-of-hospital setting. All were submersion victims. CPR
was performed by police twice, lifeguards twice, vacationing
EMTs once, a physician once, parents three times and other
bystanders in two instances. Three patients were intubated for
persistent respiratory distress, 2 for continued unconsciousness
and inability to protect the airway, 1 for apnea, and 1 had a
failed intubation attempt that was not repeated. One patient
subsequently died of adult respiratory distress syndrome and 3
had minor neuorologic sequelae. This information suggests that
CPR was prudent and perhaps life-saving for this group of
children.
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The most important message from this data is that we must
increase the number of patients with out-of-hospital cardiac
arrest who receive bystander CPR. This message is concordant
with the newly released 2005 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care.4 The 2005 Guidelines place renewed
emphasis on early, aggressive CPR with minimal interruptions
as a critical component of resuscitation. Also, the American
Academy of Pediatrics has published a report encouraging
pediatricians to promote CPR training.5 I agree with
Dr. Donoghue et al that “bystander saves” deserve more
attention and study. In the meantime, we should do all we can
to encourage laypersons and health care providers to become
proficient at something of proven value— good quality CPR.
Robert W. Hickey, MD
Children’s Hospital of Pittsburgh
Division of Pediatric Emergency Medicine
Pittsburgh, PA
doi:10.1016/j.annemergmed.2006.01.046
1. Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatric
cardiac arrest: an epidemiologic review and assessment of current
knowledge. Ann Emerg Med. 2005;46:512-522.
2. Sirbaugh PE, Pepe PE, Shook JE, et al. A prospective, population-
based study of the demographics, epidemiology, management,
and outcome of out-of-hospital pediatric cardiopulmonary arrest.
Ann Emerg Med. 1999;33:174-184.
3. Hickey RW, Cohen DM, Strausbaugh S, et al. Pediatric patients
requiring CPR in the prehospital setting. Ann Emerg Med. 1995;25:
495-501.
4. Emergency Cardiovascular Care Committee and Subcommittees of
the American Heart Association. 2005 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2005;112(suppl IV):IV-I-IV-211.
5. Pyles LA, Knapp J. Role of pediatricians in advocating life support
training courses for parents and the public. Pediatrics.
2004;114:e761-e765.
Seven Days of Gamma-Hydroxybutyrate (GHB)
Use Produces Severe Withdrawal
To the Editor:
We describe a case of gamma-hydroxybutyrate (GHB)
withdrawal precipitated by ingesting GHB every 2-3 hours
for only 7 days.
A 29-year-old healthy woman presented to the emergency
department awake, staring straight ahead, but not answering
questions and inconsistently following commands. Her
symptoms began one day earlier after abruptly stopping GHB
use. Eight days prior to presentation, the patient began to use
GHB as a sleep aid and intoxicant to help overcome personal
issues. Her frequency of dosing quickly escalated to 3 ounces
of GHB every 2-3 hours in a “round-the-clock” fashion. The
concentration of GHB remains unknown because the patient
exhausted her supply, which caused her to stop using GHB.
Annals of Emergency Medicine 219
Correspondence
Over the past year, she used GHB once or twice a month prior
to aerobic workouts. The patient occasionally drank alcohol and
smoked cigarettes. The history was reported by a roommate and
later confirmed by the patient.
On arrival her blood pressure was 145/95 mm Hg, pulse 132
beats/min, respirations 16 breaths/min, and oral temperature
of 37.2°C (98.7°F). Her pupils were 7 mm and reactive and
without nystagmus. Her mucous membranes were dry; neck was
supple; and abdomen was soft with bowel sounds. Her skin was
cool and dry without a rash. A limited neurologic exam found
normal tone and reflexes without tremor or clonus.
Her electrocardiogram revealed a narrow complex sinus
tachycardia of 140 beats/min. Her laboratory work up,
including routine urine drug screen for amphetamines,
barbiturates, benzodiazepines, cocaine, and opioids, was non-
contributory. One liter of normal saline failed to reduce
(decrease) her tachycardia.
During the subsequent 24 hours she developed increasing
agitation, delirium, insomnia, and visual hallucinations. Her
pulse rate and blood pressure increased and the patient became
diaphoretic. A continuous lorazepam infusion was initiated and
continued for two days, which reversed her tachycardia while
producing a somnolent state. While in the ICU she received a
total of 56 mg of lorazepam, and was discharged on a low dose
taper of lorazepam.
Prior to this report, severe GHB withdrawal has only been
described in the context of long-term and frequent, almost
continuous daily use of GHB and related compounds. Most
previous cases of withdrawal are precipitated by round-the-clock
GHB abuse every 2-3 hours for several months to years.1–3 The
shortest previously reported induction period described is 2
months.1
220 Annals of Emergency Medicine
Short induction periods have also been described for other
agents that commonly produce withdrawal. Ethanol
administered daily can induce withdrawal in as little
as 16 days,4 and administration of benzodiazepine and
opioids can induce withdrawal in as little as 7 days.5
This case demonstrates that severe GHB withdrawal can be
induced by a short, 7-day induction period. Milder symptoms
are likely after shorter periods of use. Patients who present
following frequent use of GHB for even short periods should
be evaluated for signs of withdrawal.
Eric Perez, MD
Jason Chu, MD
Theodore Bania, MD
Department of Emergency Medicine
St Lukes/Roosevelt Hospital
New York, NY
doi:10.1016/j.annemergmed.2006.03.040
1. Dyer JE, Roth B, Hyma B. Gamma-hydroxybutyrate withdrawal
syndrome. Ann Emerg Med. 2001;37:147-153.
2. McDaniel CH, Miotto K. Gamma hydroxybutyrate (GHB) and gamma
butyrolactone (GBL) withdrawal: five case studies. J Psychoactive
Drugs. 2001;33:143-149.
3. Miotto K, Darakjian J, Basch J, et al. Gamma-hydroxybutyricacid:
patterns of use, effects and withdrawal. Am J Addict. 2001;10:
232-241.
4. Isbell H, Fraser HF, Wikler A, et al. An experimental study of the
etiology of “rum fits” and delirium tremens. Q J Stud Alcohol.
1953;16:1-33.
5. Cammarano WB, Pittit JF, Weitz S, et al. Acute withdrawal
syndrome related to the administration of analgesia and sedation
in adult intensive care patients. Crit Care Med. 1998;26:676-684.
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