Ingestion

A 2-year-old male presents to the emergency department after being found unresponsive.  

The patient was brought to the emergency department by family after being found unresponsive at home. His mother reports that he had been playing unsupervised for approximately 20 minutes before she found him limp on the couch and was having trouble waking him up. She discovered an open purse belonging to his visiting grandmother containing loose pills and several prescription bottles, though his mother does not remember which. The grandmother does have chronic back pain, depression, and hypertension which are currently being treated. The patient is otherwise healthy, full vaccinated, and has no history of seizures, trauma, or recent illnesses.  

Vitals: T 36.8°C, HR 95 bpm, RR 10/min, BP 90/58 mmHg, SpO₂ 87% on room air. 

General: Only arousing to painful stimuli, pale, cyanotic lips. 

HEENT: Pinpoint pupils bilaterally, moist mucous membranes. 

Lungs: Clear to auscultation bilaterally, no increased work of breathing, visibly bradypneic (low respiratory rate). 

Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs. Strong distal pulses with 2 second capillary refill. 

Abdomen: Soft, nontender and nondistended, normal bowel sounds.  

Neurologic: Awakes only to painful stimuli, pinpoint pupils bilaterally, withdraws all extremities to painful stimuli.  

Skin: No rash or petechiae. 

The evaluation of a pediatric patient with a toxicology emergency requires a careful detailed history to determine potential exposures as well as a thorough physical exam with particular attention to patterns of toxidromes. 

The following chart is a helpful guide to the vital signs and physical exam findings associated with common pediatric toxidromes:

Table 2. Common toxidromes by associated vital signs including heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (T), physical exam findings, and example medications/exposures. 

Prompt recognition of an ingestion and early identification of the toxidrome are essential to initiate timely and potentially life-saving interventions. Immediate priorities at the time of arrival are assessment of airway and breathing (ABC’s, as discussed earlier), reversal of opioid effect, and monitoring for associated complications.  

Initial Evaluation: 

• Point-of-care testing: 

• • Obtain point-of-care glucose to assess for hypoglycemia as the patient presented with altered mental status. 

• Laboratory evaluation: 

• • Obtain CBC, CMP, and potentially a VBG to assess for electrolyte disturbances or acid-base disorders, in this case likely a primary respiratory acidosis in the setting of hypoventilation.  

• Toxicologic evaluation: 

• • All patients should have a urine drug screen including a saved specimen for future testing, as well as serum levels for acetaminophen, ethanol, and salicylate. 

• Further testing: 

• • Obtain EKG to assess for cardiac conduction abnormalities which may occur with certain ingestions. 

Management: 

In this case, the constellation of altered mental status, respiratory depression, and miosis strongly suggests the diagnosis of opioid toxicity. 

• Obtain intravenous (IV) access. 

• Administer Naloxone without delay (which can be administered via various routes, commonly intranasal).  

• Further doses of naloxone can be administered every two to three minutes as needed to restore breathing and a stable airway.  

• Provide supplemental oxygen as needed and prepare for an advanced airway if mental status deteriorates or respiratory effort is inadequate despite naloxone.  

The mainstay of treatment for opioid toxicity is naloxone.  

Naloxone is a pure competitive antagonist of the opiate receptor. It can be administered by various routes, commonly intranasal or intravenous though it can also be administered via the intramuscular, subcutaneous, or endotracheal routes.  

It is important to always consider toxidromes as a cause of altered mental status.  

In this case, the triad of altered mental status, respiratory depression, and miosis is characteristic of opioid toxicity. 

Answers

Q1. True. Naloxone doses can be repeated every two to three minutes to restore breathing and a stable airway. At times, a continuous infusion may even be necessary as the duration of effect of the opioid may be longer than the half-life of Naloxone.  

Q2. True. Both sympathomimetic and anticholinergic toxidromes have significant overlap including mydriasis, tachycardia, agitation, hallucinations/delirium, and hypertension. However, diaphoresis is a key distinguishing feature present in sympathomimetic toxicity but absent in anticholinergic toxicity, where the skin and mucous membranes are dry.  

Q3. C. Diaphoresis and hyperactive bowel sounds point instead to a sympathomimetic toxidrome while the other answers are all consistent with anticholinergic toxicity.  

• American College of Clinical Pharmacy: Pediatric Poisonings. 
  https://www.accp.com/docs/bookstore/pedsap/ped2023b1_sample.pdf
• UpToDate: Opioid intoxication in children and adolescents.
• StatPearls: Opioid Toxicity.