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mg/kg IV If there is no response despite the suspicion of opiate intoxication, the naloxone dose should be repeated (up to a total dose of to 10 mg), depending on effect and level of suspicion γ-Hydroxybutyrate, γ-Hydroxybutyrolactone, and 1,4Butanediol Current Evidence The related agents, γ-hydroxybutyrate (GHB), γ-hydroxybutyrolactone (GBL), and 1,4-butanediol (1,4 BD), became popular substances of abuse among teenagers and young adults in the late 1990s and early 2000s These agents are used for a variety of reasons, but primarily as euphoriants and aphrodisiacs at parties or all-night dance clubs (“raves”) GHB has gained a particular notoriety as a date-rape agent This class also has a reputation in the body-builder community as growth hormone stimulants and thus enhancers of muscle development and fat loss Medically, sodium oxybate (Xyrem) is available as a schedule III substance used to treat cataplexy GHB is an endogenous compound with neurotransmitter and/or neuromodulator function and interacts with dopamine, serotonin, GABA, and endogenous opioid-based neural systems GBL is actually a precursor to GHB and is rapidly metabolized in vivo to GHB, thus the clinical effects of ingesting either agent are nearly indistinguishable 1,4 BD is also metabolized to GHB via alcohol dehydrogenase Clinical Considerations GHB, GBL, and 1,4 BD are CNS depressants that cause rapid onset of deep sleep that can progress to coma and respiratory depression Patients who have overdosed may have transient seizure activity or myoclonus and are often hypothermic and bradycardic The coma is usually relatively short in duration, on the order of to hours During emergence, transient delirium and vomiting are often observed Depressed respiratory effort and airway-protective reflexes are common in the more severe cases, although aspiration pneumonia has been a rare complication Many patients are surprisingly responsive to stimulus, and attempts at laryngoscopy to effect endotracheal intubation in a seemingly deeply comatose patient may result in an angry, combative patient who sits up and swears at the endoscopist Most patients with acute overdose can be managed with the provision of ambient oxygen, suctioning, and attention to the airway A nasal trumpet is helpful in some cases, and endotracheal intubation may be required Atropine has
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