Chief Complaint: Unresponsive
Vitals: Temp 97.9 R HR 130 Resp 19 BP 118/59 PO2 93% RA
HPI:
10 month old female presents to the ED unresponsive from home. Patient was taking a nap for longer than usual today. Family was unable to arouse patient to an alert state. No cyanosis, no respiratory distress. Makes grumbling noises occasionally as per parents. Deny nausea, vomiting, no recent illness, no fever, no chills. Patient was acting normally earlier in the day. Trauma denied.
Physical Exam:
General: well developed, well nourished female, lethargic, minimally responsive
Skin: warm and dry, no rash
Head: normochephalic, atraumatic
Eyes: pupils pinpoint bilaterally, conjunctiva and sclera normal
Cardiac: normal
Resp: normal, decreased respiratory rate
Abd: normal
Neuro: lethargic, occasional groans, responsive to pain, DTRs intact, decreased tone.
Thoughts? What do you want to do first?
On further questioning:
Father recalls that 5 days prior he dropped his prescription medication on the living room floor (oxycodone 30mg and morphine ER 60 mg). Dad didn't tell mom and cleaned up as best as he could. He vacuumed and cleaned up the area, then the family went on vacation and came back yesterday. Dad states it's possible he may have not picked up some pills and she may have gotten a hold of some. Mom now recalls she noticed a pill or two on the floor by the entrance way in the area where child was playing.
Toxicology Consulted:
0.4 mg Naloxone given with immediate response, eyes opening, pupils dilating, immediate cry
Plan:
Labs
CXR - normal
EKG
Blood Gas
Ubag for Utox
ACS
PICU admission
Repeat doses of Narcan needed, patient ultimately placed on Narcan drip at 0.3mg/hr
Narcan dosing (from UTD):
IV (preferred), Intraosseous: Note: May be administered IM, SUBQ, or endotracheally, but onset of action may be delayed, especially if patient has poor perfusion; the endotracheal route is preferred if IV/Intraosseous route not available; doses may need to be repeated.
Infants and Children <5 years or ≤20 kg: IV, Intraosseous: 0.1 mg/kg/dose; repeat every 2 to 3 minutes if needed; monitor closely; may need to repeat doses (eg, every 20 to 60 minutes) if duration of action of opioid is longer than naloxone.
Children ≥5 years or >20 kg and Adolescents: IV, Intraosseous: 2 mg/dose; if no response, repeat every 2 to 3 minutes; monitor closely; may need to repeat doses (eg, every 20 to 60 minutes) if duration of action of opioid is longer than naloxone.
Endotracheal: Infants, Children, and Adolescents: Optimal endotracheal dose unknown; current expert recommendations are 2 to 3 times the IV dose.
IM, SUBQ: Note: IM or SUBQ absorption may be delayed or erratic.
Prefilled 5 mg syringe (Zimhi): Infants, Children, and Adolescents: IM, SUBQ: 5 mg (contents of 1 prefilled syringe) as a single dose; may repeat every 2 to 3 minutes if needed until emergency medical assistance becomes available.
Solutions for injection (eg, ampules, vials, prefilled 2 mg syringe): Infants, Children, and Adolescents: IM, SUBQ: 0.1 mg/kg/dose; maximum dose: 2 mg/dose; repeat every 2 to 3 minutes if needed; monitor closely; may need to repeat doses (eg, every 20 to 60 minutes) if duration of action of opioid is longer than naloxone.
Auto-injector (10 mg dose):Note: For self or buddy administration by military personnel or chemical incident responders.
Treatment: Children ≥12 years and Adolescents: IM, SUBQ: 10 mg (contents of 1 auto-injector) as a single dose; may repeat as needed until emergency medical assistance becomes available. If the patient does not show some improvement after administering the dose, consider other causes of respiratory depression. Seek immediate emergency medical assistance after administration of first dose.
Prevention: Children ≥12 years and Adolescents: IM, SUBQ: 10 mg (contents of 1 auto-injector) as a single dose administered immediately prior to entering an area believed to be contaminated with high potency opioids; may repeat if exposure to high potency opioids is prolonged.
Intranasal: Note: Onset of action is slightly delayed compared to IM or IV routes.
Intranasal formulations (eg, Kloxxado, Narcan Nasal Spray):Infants, Children, and Adolescents: Intranasal: 4 mg or 8 mg (contents of 1 nasal spray) as a single dose; may repeat every 2 to 3 minutes in alternating nostrils if needed until medical assistance becomes available (Ref).
Solution for injection (1 mg/mL injection) for intranasal administration: Adolescents ≥13 years: Intranasal: 2 mg (1 mg per nostril). Note: Naloxone 0.4 mg/mL parenteral formulation has been evaluated and may be used for opioid overdose; however, due to the volume needed to administer the dose it is not ideal for nasal administration; should be used if intranasal administration is needed and a more concentrated naloxone is not readily available.
Continuous IV infusion: Limited data available: Infants, Children, and Adolescents: Continuous IV infusion: 24 to 40 mcg/kg/hour has been reported (Ref). Doses as low as 2.5 mcg/kg/hour have been reported in adults and a dose of 160 mcg/kg/hour was reported in one neonate (Ref). If continuous infusion is required, calculate the initial dosage/hour based on the effective intermittent dose used and duration of adequate response seen (Ref) oruse two-thirds (2/3) of the initial effective naloxone bolus given as the hourly infusion (Ref); titrate dose; Note: The infusion should be discontinued by reducing the infusion rate in decrements of 25%; closely monitor the patient (eg, pulse oximetry, respiratory rate) after each adjustment and after discontinuation of the infusion for recurrence of opioid-induced respiratory depression.
Important Pearl:
Avoid anchoring bias and keep your mind open to every differential.
Thanks for reading.
Podcast on Altered Mental Status in Children:
https://podcasts.apple.com/us/podcast/pediatric-emergency-playbook/id1035668219?i=1000367847450