Abstract 15164: Refractory Shock Following Ingestion of Gamma Hydroxy Butyrate Laced With Xylazine

Abstract

Case: A 35 year old male with a complex psychiatric history including previous suicide attempts was brought to the emergency department after being found on a sidewalk with bradycardia and bradypnea by emergency medical services (EMS). He responded to naloxone administered by EMS and admitted to using heroin, gamma hydroxyl butyrate (GHB), and rohypnyol prior to becoming unconscious. On arrival, his vitals showed a sinus heart rate at 60, decreased respiratory rate with normal oxygenation, hypotension with systolic blood pressures in the 50’s, and hypothermia with a temperature of 95 degrees Fahrenheit. On physical exam his heart rate and rhythm were regular, lungs were clear to auscultation, he had pinpoint pupils, and was perfusing his extremities well with normal capillary refill without diaphoresis. A bedside echocardiogram showed normal left ventricular ejection fraction without signs of cardiogenic shock. He was subsequently started on two pressors but continued to clinically worsen requiring overmaxed doses of five pressors including Angiotensin II. He continued to clinically decline with worsening renal failure requiring CRRT therapy and remains ventilator dependent. Discussion: This patient was admitted to the intensive care unit for profound vasoplegic shock. The etiology of his shock was due to a veterinary drug called xylazine. Xylazine is a horse tranquilizer which is commonly laced in drugs of abuse including GHB. It’s an alpha 2 agonist which causes decreased sympathetic outflow and decreased norepinephrine release leading to a clinical presentation including profound hypotension, bradycardia, CNS depression, and miosis. While it can mimic opioid toxicity patients tend to have preserved respiratory status and transiently respond to painful stimulation. Patients who don’t concomitantly use opioids, do not typically respond to naloxone. It is critical to consider this in the differential in patients with an opioid toxidrome who don’t respond to naloxone. The treatment for xylazine overdose is supportive care of their hemodynamics. The half-life of the drug is around 48 hours but can persist for several days. While xylazine overdose generally carries a good prognosis, it can still lead to devastating consequences.