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.

Okay, if your patient presents with bradycardia with or without hypotension, you should consider alcohol, opioid, or sedative-hypnotics exposure.

Here’s a high yield fact! Other important physical exam findings that should make you think of alcohol, opioid, and sedative-hypnotics exposure include hypothermia, sedation, miosis, respiratory depression, and hyporeflexia.

First, let’s focus on alcohol exposure! These patients typically report abdominal pain, nausea, and vomiting, while their physical exam typically reveals ataxia and agitation. Additionally, lab results will reveal a positive serum ethanol concentration, in which case you can diagnose alcohol exposure.

Here’s a clinical pearl! Alcohol exposure can lead to hypoglycemia, so don’t forget to obtain a point-of-care glucose level if you suspect alcohol intoxication.

Next up are opioids. These are often associated with constipation. In this case, your patient will often be euphoric with decreased bowel sounds, and possibly needle marks. Additionally, the urinary drug screen will be positive for opioids. If so, you can diagnose opioids as the source of the recreational substance exposure.

Okay, now let’s look at a patient exposed to sedative-hypnotics. In this case, the physical exam typically reveals nystagmus and ataxia; and the urinary drug screen is positive for either benzodiazepines or barbiturates. In this scenario, diagnose sedative hypnotics as recreational substance exposure. Just like opioids, benzodiazepines can have false negatives on the urine drug screen, which is especially common in commonly abused medications, such as lorazepam, alprazolam, midazolam, and clonazepam.

Alright, now, let’s back up and take a look at patients with tachycardia and possibly hypertension. In these patients, your next step is to assess for hallucinations.

If hallucinations are absent, consider exposure to stimulants, marijuana, or inhalants. First, let’s focus on stimulants. Say your patient’s physical exam reveals they are hyperthermic; experiencing delusions and paranoia; as well as have mydriasis or dilated pupils; hyperreflexia; diaphoresis; and piloerection. The urine drug screen will likely be positive for amphetamines or cocaine. In this case, diagnose recreational exposure to stimulants, which include amphetamines, like pseudoephedrine; MDMA, also called molly or ecstasy; and cocaine.

Here’s a clinical pearl! MDMA is often used in the club scene. What’s important to keep in mind is that sodium loss from physical exertion while dancing combined with increased free water intake can cause hyponatremia. So, don’t forget to check electrolyte levels in these patients.