Club Drugs (ALS) > History Of Present Illness

Your EMS crew is dispatched to the scene of a private house at 6:30 AM where two
young women had just returned from partying all night. You arrive to find Jessica,
your patient, lying on the floor in a pool of vomit. Jessica’s “friend” appears to be
intoxicated and says that they had been drinking all night. Jessica seemed fine until
about 10 minutes ago when she suddenly fell on the floor and “I couldn’t wake her
up. Her body started making these jerky movements”. Jessica is unresponsive and
unable to give any history.

Past medical history : Unknown (her “friend” says she doesn’t think she has any
medical problems)

Medications : Unknown (her “friend” says she doesn’t think she takes any
medications)

Allergies : Unknown

Social history : Smokes “when she’s drinking,” alcohol on weekends, her “friend” says
she doesn’t use drugs

Vital  signs : 

 Temp  deferred

 BP  110/70

 Resp  4 (agonal)

 Pulse  110(regular)

 O 2 sat  70% on room air

Physical Exam

General:  Unresponsive, flaccid, lying in vomit, mouth is full of vomit 

HEENT:  No evidence of trauma 
Neck:  No JVD, no evidence of trauma 
Lungs:  Agonal respirations, diminished breath sounds 
Cardiac:  Tachycardic, regular 
Abdomen:  Soft 
Back:  Unremarkable 
Extremities:  No evidence of trauma, no pedal edema 
Skin:  Dry, covered in vomit, no track marks on arms 
Neuro:  Unresponsive, nonverbal, GCS 3 

Assessment Of This Case

This patient has an immediate ABC problem and needs immediate airway control. If
she can tolerate an oral airway, one should be placed. Her breathing should be
supported by manual ventilation with a bag valve mask (BVM). If paramedic care is
available, preparations for intubation should be made. If available, this patient
requires the following: blood sugar check, narcan (to reverse
possible opiate overdose), and thiamine. If possible, one may consider these 3
things be done prior to intubation because if the patient responds to narcan, she
may not require intubation. A low blood sugar that is promptly reversed with D50
may also help prevent intubation.

ABC's

Airway : Airway not secure

Breathing : Agonal respirations with hypoxia
Circulation : Pulses are present

Differential Diagnosis - Altered Mental Status

Clinical Features Of GHB

 Feelings of euphoria, intoxication, aphrodisiac, drowsiness, dizziness, visual

disturbances

 Respiratory depression with apnea, interrupted by periods of agitation and

combativeness

 Behavioral changes ranging from aggression and delirium to coma

 Pinpoint pupils (not always)

 Vomiting (50% of cases)

 Seizures

 Bradycardia
  Myoclonic jerking movements

 Exists naturally in the brain, but at much lower concentrations than during

the abuse of GHB.5

 Street cost: $5-10 per dose

Street Names For GHB

 GHB

 GBH

 Gib

 Gamma-OH

 Liquid X

 Liquid E

 Liquid G

 Soap

 Scoop

 Easy lay

 Fantasy

 Grievous Body Harm

 Georgia home boy

 Natural sleep-500

 Gamma hydrate

 Organic Quallude

 Liquid ecstasy

 Somatomax

 Salty water

 Sodium oxybate

 Cherry menth

 G-Riffick

Treatment For GHB Overdose

Aggressive airway protection is essential. The combination of vomiting and
respiratory depression makes GHB a very dangerous drug of abuse. There is no
antidote. Be sure to have the patient well secured to the stretcher before intubation
as these patients are notorious for extubating themselves and aspirating. These
patients are at very high risk for aspiration. Narcan is not effective in reversing the
effects of GHB, as GHB is not a narcotic. Dangers of self-extubation include vocal
cord trauma, aspiration, hypoxia, and tracheal rupture.

Case Review

In this particular patient’s situation, you would be more suspicious of alcohol

intoxication or drug ingestion because of the events surrounding the call. But, as
always, a full secondary survey should be conducted with a search for possible
clues. Perhaps this patient has a history of seizures, which may be determined from
a medical alert bracelet. Perhaps she slipped and fell from alcohol intoxication but
hit her head and now has a subdural hematoma. Perhaps the patient wasn’t
drinking at all but had a cerebral aneurysm rupture and now has a subarachnoid
hemorrhage. Although some type of alcohol or drug ingestion is the most likely
situation, a thorough search for other possibilities should always be done. A
thorough history and physical exam, thoroughly surveying the scene, looking for
medical alert bracelets, and following standard protocols will avoid overlooking a
possible diagnosis.

Treatment Sequence (For All Patients With Altered Mental Status)

 Scene safety and scene survey  – search for clues to explain mental status (history
from bystanders, check wallet and pockets for clues) 

 ABCs  – this patient is hypoxic, unresponsive, and needs airway control

(suggest narcan, thiamine, and blood sugar determination while preparing for
intubation) 

 Complete set of vitals  (including temperature when possible) 

 Cervical spine precautions , if possible trauma

 Complete secondary survey

 Continuous monitoring, transport

 Secure intubated patients to prevent  extubation

Tip Of The Month

Patients taking GHB will often appear comatose and may become suddenly alert
and oriented. Intubated patients suspected of GHB overdose need to be well
secured to prevent extubation. 
Definition

Club Drugs  – general term for illicit drugs commonly abused at nightclubs and

“raves”.

 Ecstasy - "X, E, XTC, Adam, M&M, Bean Roll, Clarity, Essence"

 Structurally related to both methamphetamine and mescaline.

 Tablets are often round and white with various imprints or logos on the
tablets.

 Alterations in colors or sensations of textures, euphoria, enhanced sociability,

verbosity, heightened sexual interest, "feel good" drug.

 Popular club drug that acts as a stimulant - hallucinations, decreased

appetite, increased heart rate and blood pressure,
increased body temperature, bruxism (teeth grinding), dilated pupils, muscle
cramping, panic attacks, loss of consciousness, seizures.

 Abnormal cardiac rhythms are managed with standard medications.

 Clinical caveat: hypertension and tachycardia may be managed

with benzodiazepines.

 Street cost: $25 per pill; $200-250 for a blister pack of 10. 4

Methamphetamine - "Crystal, Meth, Crystal Meth, Ice, Tina, Crank"

 Methamphetamine powder is often smoked in a pipe, injected, or swallowed. 

 Initial stimulating rush, severe agitation, violent and dangerous behavior,

delusions, hallucinations, and paranoia. 

 Heavy users may stay awake for days. 

 Can damage nerve cells causing brain damage. 

 Withdrawal effects: abdominal cramps, vomiting and diarrhea, headache,

lethargy, breathing troubles, increased appetite, severe depression. 

 Clinical caveat: ensure scene safety as these patients can often become
violent.

Ketamine - "Special K, K, Vitamin K, Fort Dodge"

 Inhaled, injected, orally, smoked.

 Increases blood pressure, heart rate, muscle tone, salivation.

  Brain-body dissociation: “out-of-body experience”, vomiting, fatigue, lack of
responsiveness, delirium, amnesia, depression.

 Clinical caveat :  these patients may become delusional or have nightmares

as they emerge from the drug.

 Street cost: $25 per capsule or small amount of powder; $150-300 per vial
of liquid. 4

Rohypnol - "Roofies, Roaches, Ropies"

 Fast-acting benzodiazepine – 10 times stronger than Valium.

 Same class of drug as Valium, Versed, and Ativan.

 Initial “date-rape drug” – causes significant sedation, victims unable to

defend themselves, causes amnesia.

 Clinical caveat : contact the appropriate authorities if there is any suspicion

that a patient may have been sexually assaulted.

"Acid"

 Potent psychoactive agent

 “Blotter paper” with fancy designs is common mode of ingestion

 Psychedelic drug – “LSD trip”

 Increased sympathetic response – dilated pupils, elevations in pulse

and blood pressure, elevated temperature, respiratory
arrest, seizure and coma

"Angel Dust"


Hallucinogen - dissociative anesthetic agent similar structurally to ketamine
 Symptoms vary from CNS stimulation to CNS depression – physically violent or catatonic
 Violent (35%), agitated (34%), bizarre behavior (29%), hallucinations or delusions
(19%), tachycardia (30%), hypoglycemia (22%), coma (11%), seizures (3%)
 Clinical caveat : ensure scene safety. These patients can become very violent.

What Happened To Our Patient?

Our patient was using GHB (Gamma Hydroxybutyrate), a common

club drug being increasingly used throughout the United States. GHB is
available as an odorless, colorless, and nearly tasteless liquid, powder,
or capsule. GHB was originally synthesized in 1960 and was initially used as
an anesthetic in Europe and Japan. It was pulled from the U.S. market in
1990 because of its many adverse reactions. It now is commonly used as a
drug of abuse for its possible muscle building properties, fat-burning
 properties, and psychoactive effects. Late night rave parties are common
locations for GHB abuse. It has also been used as a date rape drug. Like
other sedatives, its effects include CNS depression, amnesia, and loss of
inhibition.

Glossary

Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may

be physical, sexual, psychological, or financial/material.
Agitation  : Extreme restlessness and anxiety.
Agonal  : Pertaining to the period of dying.
Agonal Respirations  : Slow, shallow, irregular respirations or occasional gasping
breaths; results from cerebral anoxia.
Anesthetic  : A type of medication intended to induce a loss of sensation to touch or
pain.
Aneurysm  : A swelling or enlargement of part of a blood vessel, resulting from
weakening of the vessel wall.
Behavior  : The way people act or perform, for example how they react/respond to a
situation.
Body  : In the context of the uterus, the portion below the fundus that begins to
taper and narrow.
Brain  : Part of the central nervous system located within the cranium; contains
billions of neurons that serve a variety of vital functions.
Capsule  : A cylindrical gelatin container enclosing a dose of medication.
Coma  : A state in which one does not respond to verbal or painful stimuli.
Delirium  : Change in mental status that is marked by the inability to focus, think
logically, and maintain attention.
Depression  : A persistent mood of sadness, despair, and discouragement; may be a
symptom of many different mental and physical disorders, or it may be a disorder
on its own.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate
circumstances and in the appropriate dose.
Drug Abuse  : Any use of drugs that causes physical, psychological, economic, legal,
or social harm to the user or others affected by the user's behavior.
Drugs  : Any chemical compounds that may be used on humans to help in diagnosis,
treatment, cure, mitigation, or prevention of disease or other abnormal conditions.
Edema  : A condition in which excess fluid accumulates in tissues, manifested by
swelling.
Hypertension  : High blood pressure, usually a diastolic pressure greater than 90 mm
Hg.
Hypoglycemia  : Abnormally low blood glucose level.
Illicit  : In relation to drugs, illegal drugs such as marijuana, cocaine, and LSD.
Ingestion  : Eating or drinking materials for absorption through the gastrointestinal
tract.
Methamphetamine  : A highly addictive drug in the amphetamine family.
Mode  : The most common number in any given research project.
Opiate  : Various alkaloids derived from the opium or poppy plant.
Powder  : A drug that has been ground into pulverized form.
Rape  : Sexual intercourse inflicted forcibly on another person, against that person's
will.
Seizure  : A paroxysmal alteration in neurologic function, ie, behavioral and/or
autonomic function.
Sepsis  : A pathologic state, usually in a febrile patient, resulting from the presence
of invading microorganisms or their poisonous products in the bloodstream.
Tachycardia  : A rapid heart rate, more than 100 beats/min.
Term  : Used to describe an infant delivered at 38 to 42 weeks of gestation.
Track Marks  : The visible scars from repeated cannulation of a vein; commonly
associated with illicit drug use.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result
of the rapid dissipation of energy delivered by an external force.
Ventilation  : The process of moving air into and out of the lungs.

References