Violence against women and drug-facilitated sexual assault (DFSA): A review of the main drugs.

Sexual violence is a universal phenomenon without restriction to sex, age, ethnicity or social class that causes devastating effects in the physical and mental health spheres, in the short-term and long-term, such as pregnancy, sexually transmitted infections (STI) and greater susceptibility to psychiatric symptoms, especially depression. Some cases of sexual assault and rape are based on the use of so-called drug-facilitated sexual assault (DFSA), which cause victims' loss of consciousness and inability to defend, making them vulnerable to violence. Thus, this article aimed to review the literature on gender violence and the drugs used to facilitate sexual assault, addressing their mechanism of action and pharmacokinetics, as well as drug detection times in human body and types of forensic identification. It is understood that the knowledge of these drugs and their pharmacological and diagnostic mechanisms should be widely disseminated, especially about sensitivity tests and the time the drug remains in the body, which would validate the promotion of evidence to prove abuse, and, thus, being able to give a promising outcome to cases of aggression, which is extremely beneficial for women.

Symptoms and signs in interpreting gamma-hydroxybutyrate (GHB) intoxication - an explorative study.

BACKGROUND: Acute poisoning with gamma-hydroxybutyrate (GHB) has been a serious medical and social problem in different parts of the world including Sweden. GHB is a drug of abuse which acts primarily as central nervous system (CNS) depressants. GHB has serious toxicity, although many young users do not recognise GHB as a dangerous drug. The aim of this pilot study was to explore how symptoms with risk of failure in vital functions would be valued among professionals that encounter GHB intoxication in the emergency phase. METHODS: A web-based survey focusing on the assessment of vital clinical signs for possible GHB intoxication using a numeric scale was carried out during April and May 2011. The participants, n 105, are all professionals who encounter GHB intoxicated in the emergency phase, but have different levels of training in GHB intoxication, mainly Registered Nurses (RNs) in southwest Sweden, employed in pre-hospital or emergency departments at somatic and most psychiatric health care facilities, as well as police officers who in their work come into contact with drug users. Responses in the survey were scored according to risk of GHB intoxication with serious failure of vital functions. The score value was then referred to a so-called evidence based priority (EBP) scale and analysed using descriptive statistics and Fisher's exact test. RESULTS: Cardiac arrest, coma, hypoxia, general convulsions, slow respiratory and heart rate and pale skin are symptoms with the highest risk of serious failure in vital physical functions and were predominantly recognised as such. CONCLUSION: Despite the professionals' different levels of training in GHB intoxication, all of them were relatively well aware of and in accordance regarding the most risky symptoms. The interpretation score for the less risky symptoms and signs of GHB intoxication varied depending on their degree of training. The results should be viewed cautiously, as the size of the professional groups and their general knowledge of critical symptoms of GHB poisoning varied.

Hospital in the field: prehospital management of GHB intoxication by medical assistance teams.

INTRODUCTION: Recreational use of gamma-hydroxybutyrate (GHB) is increasingly common at mass-gathering dance events in Australia. Overdose often occurs in clusters, and places a significant burden on the surrounding health care infrastructure. OBJECTIVE: To describe the clinical presentation, required interventions and disposition of patrons with GHB intoxication at dance events, when managed by dedicated medical assistance teams. METHODS: Retrospective analysis of all patrons attending St. John Ambulance medical assistance teams at dance events in the state of Victoria (Australia), from January 2010 through May 2011. Main outcome measures Clinical presentation, medical interventions and discharge destination. RESULTS: Sixty-one patients with GHB intoxication attended medical teams during the study period. The median age was 22 years, and 64% were male. Altered conscious state was present in 89% of attendances, and a GCS <9 in 44%. Hypotension, bradycardia and hypothermia were commonly encountered. Endotracheal intubation was required in three percent of patrons. Median length of stay onsite was 90 minutes. Ambulance transport to hospital was avoided in 65% of presentations. CONCLUSIONS: The deployment of medical teams at dance events and music festivals successfully managed the majority of GHB intoxications onsite and avoided acute care ambulance transfer and emergency department attendance.

Physostigmine for gamma-hydroxybutyrate coma: inefficacy, adverse events, and review.

Physostigmine has been proposed as an antidote for gamma hydroxybutyrate (GHB) intoxication, based on associated awakenings in 1) patients anesthetized with GHB and 2) five of six patients administered physostigmine for GHB intoxication. However, there are neither well-supported mechanisms for physostigmine reversal of GHB effects, supportive animal studies, nor randomized, placebo-controlled trials demonstrating safety, efficacy, or improved outcomes. We sought to determine the outcomes of patients with GHB-induced coma after a physostigmine treatment protocol was instituted in an urban Emergency Department and ambulance service. Our search of medical records located five cases of GHB toxicity, all with co-intoxicants, who received physostigmine. None demonstrated response and, further, there were associated adverse events, including atrial fibrillation (2), pulmonary infiltrates (1) and significant bradycardia (1), and hypotension (1). We also reviewed 18 published GHB toxicity case series for incidence of adverse effects, stimulant co-intoxicants (which may heighten risk of physostigmine), complications, and outcomes of supportive care for GHB toxicity. We conclude that physostigmine is not indicated for reversal of GHB-induced alteration of consciousness; it is not efficacious, it may be unsafe, particularly in the setting of recreational polydrug use; and supportive care results in universally good outcomes.

Pentobarbital poisoning in Sumatran tigers (Panthera tigris sumatrae).

Three Sumatran tigers (Panthera tigris sumatrae) at the Heidelberg Zoo in Germany presented with severe neurologic signs. Physical examination and diagnostic tests did not reveal a definitive diagnosis. Two days after initial presenting signs, all of the animals appeared clinically normal. An investigation into this outbreak revealed that all animals received horse meat on the evening before the incident. A toxicologic examination was initiated and serum analysis of the affected female tiger cub and the horse meat revealed contamination with pentobarbital.

Agitation is common in gamma-hydroxybutyrate toxicity.

Gamma-Hydroxybutyrate (GHB)-related compounds are most commonly described as depressants, with emphasis on somnolence, obtundation, stupor, and coma (SOSC). We sought to demonstrate the full spectrum of clinical presentations of GHB intoxication, including agitation and other nonsedative effects. Our observational study identified 66 patients with GHB toxicity, 40 of whom manifested agitation; 25 had agitation before or after SOSC, 10 had agitation alternating abruptly with SOSC, and 5 had agitation only. Fourteen presentations also included "bizarre" or self-injurious behaviors. Of 40 presentations with agitation, 19 had stimulant co-intoxicants confirmed by screen (14) or history (5). The remaining 21 patients with agitation were negative for stimulants by screen (12) or history (9). Gas chromatography/mass spectrometry detected GHB in 25 cases; 12 manifested agitation, 4 of which also screened negative for stimulants. Clinicians should broaden their definitions of GHB toxicity to include nonsedative effects such as agitation, combativeness, and bizarre or self-injurious behavior.

Gamma-hydroxybutyrate, gamma-butyrolactone, and 1,4-butanediol: a case report and review of the literature.

GHB, GBL, and 1,4-BD are prevalent drugs of abuse in the United States. Unfortunately, attempts to regulate GHB have been circumvented by clandestine trafficking through the Internet and marketing of "natural" chemical precursors . Despite repeated FDA warnings to the public about their dangers as well as recent federal scheduling of GHB and GBL, they remain accessible as "club drugs" on Internet websites, as natural dietary supplements in health food stores, and as illicit products manufactured at home or in clandestine laboratories. EDs and poison control centers nationwide will undoubtedly continue to manage GHB, GBL, and 1,4-BD toxicities.

Clinical course of gamma-hydroxybutyrate overdose.

STUDY OBJECTIVE: To describe the clinical characteristics and course of gamma-hydroxybutyrate (GHB) overdose. METHODS: We assembled a retrospective series of all cases of GHB ingestion see 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 degrees 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 < or = 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.

A tale of novel intoxication: seven cases of gamma-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.

A tale of novel intoxication: a review of the effects of gamma-hydroxybutyric acid with recommendations for management.

gamma-Hydroxybutyric acid (GHB) is unfamiliar to many physicians in the United States but enjoys clinical use elsewhere for applications in resuscitation, anesthesia, and addiction therapy. Use within the United States is restricted to Food and Drug Administration-approved clinical trials for treatment of narcolepsy. Recently illicit use of GHB has emerged within the United States where it is distributed for purported euphoric and "fat-burning" metabolic effects. Clinical effects can be severe, progressing rapidly to respiratory arrest and death. We provide an updated comprehensive review of the literature with particular emphasis on toxicology, including GHB pharmacodynamics, clinical effects, and suggestions for overdose management. Recommended management of acute GHB intoxication includes prevention of aspiration, use of atropine for persistent symptomatic bradycardia, consideration of neostigmine as a reversal agent, and treatment for coingested substances. Emergency physicians are urged to become familiar with GHB because of its potential for severe morbidity as well as its potential use as a future resuscitative agent.