Approach to recreational substance exposure (pediatrics): Clinical sciences

Recreational substances are substances taken for enjoyment or psychoactive effects without medical justification. They often include alcohol, marijuana, over-the-counter medications, and inhalants. Substance use is common amongst the pediatric population, especially during the adolescent years. However, initial exposure can begin much earlier. Now, based on clinical manifestations, we can categorize recreational substance exposure into those associated with tachycardia and possibly hypertension, versus those associated with bradycardia and potentially hypotension.

Now, if a pediatric patient presents with recreational substance exposure, you should first perform an ABCDE assessment to determine if the patient is unstable or stable. If the patient is unstable, stabilize the airway, breathing, and circulation, and consider intubation if the patient is apneic or has shallow, ineffective respirations. Next, obtain IV access, give IV fluids, and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry. If needed, provide supplemental oxygen, measure glucose, and obtain an ECG. Finally, don’t forget to consider administering naloxone if the possible offending agent is an opioid.

Now that we reviewed unstable patients, let’s go back to the ABCDE assessment and look at stable ones. In this case, obtain a focused history and physical examination, which can be difficult in a patient with recreational substance exposure, so you might want to ask accompanying friends or family to provide details. The history could reveal a known acute recreational substance exposure or a previous history of substance use; while the physical exam will show signs of altered mental status.

At this point you should suspect substance exposure! Your next step is to obtain a urine drug screen, along with a serum ethanol concentration. Next, assess the patient’s cardiovascular status to narrow down what recreational substance exposure occurred.

Now, here’s a clinical pearl! A typical urinary drug screen is not comprehensive, but it does include many common recreational substances, including amphetamines, barbiturates, benzodiazepines, cocaine, opiates, phencyclidine, and marijuana. Don’t forget that urinary drug screens can provide false positives and negatives, which is especially common with synthetic and semi-synthetic opioids, such as oxycodone and fentanyl, so obtaining a good history and physical examination is important.