Approach to recreational substance exposure (pediatrics): Clinical sciences

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Introduction0:00–0:43

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.

Unstable Patient0:43–1:28

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.

Stable Patient1:28–2:00

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.

Suspect substance exposure2:00–2:52

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!

Bradycardia with or without Hypotension2:52–3:18

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.

Alcohol3:18–3:51

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.

Opiates/Opioids3:51–4:12

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.

Sedative-Hypnotics4:12–4:48

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.

Tachycardia with or without Hypertension4:48–4:59

In these patients, your next step is to assess for hallucinations. If hallucinations are absent, consider exposure to stimulants, marijuana, or inhalants.

Stimulants/Sympathomimetics4:59–5:59

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. Okay, now let’s look at a patient with marijuana exposure.

Marijuana5:59–7:25

In this case, history often reveals anxiety and vomiting. Additionally, during the exam, the patient might look sedated, or they could present with psychosis, agitation, and delirium.
They will also have mydriasis. Finally, the urine drug screen is positive for THC metabolites, so diagnose marijuana as a recreational substance exposure.Here’s a high-yield fact to keep in mind!
Chronic exposure to marijuana can result in cannabis hyperemesis syndrome, which is associated with recurrent nausea and vomiting that is relieved with cessation of marijuana use and a hot shower!Here’s a clinical pearl!
When THC, the active component of marijuana, is inhaled through vaping, there is concern for lung injury, known as e-cigarette or vaping associated lung injury, or EVALI for short, so the patient may present with cough, shortness of breath, and chest pain.
Speaking of e-cigarettes, it’s important to remember that, though patients exposed to e-cigarettes do not generally present for medical assistance, they can lead to nicotine toxicity in high doses.
This is especially concerning if the vial of liquid nicotine breaks allowing for ingestion or skin absorption. Less than half a teaspoon can be fatal to a toddler!Finally, let’s take a look at a patient with inhalant exposure.

Inhalants7:25–8:43

These patients typically report lightheadedness or dizziness, and on physical exam the patient is either euphoric or sedated, with slurred speech, hyporeflexia, perioral dermatitis, epistaxis, and nasal ulcers.
You may even notice paint on the hands, nose, or mouth. The urine drug screen is often negative.With these signs and symptoms, you should consider inhalant exposure, so your next step is to order a urine drug screen for hydrocarbon metabolites, as well as an electrocardiogram.
If the urine drug screen is positive for hydrocarbon metabolites, with or without a dysrhythmia on the ECG, diagnose inhalants as the recreational substance exposure.
Inhaling also goes by the name “huffing”, amongst other terms, and substances abused for their psychoactive effects include hydrocarbon compounds found in cleaners and aerosols, as well as nitrous oxide, like in cans of whipped cream.Here’s a clinical pearl!
The perioral dermatitis from chemical irritation of the skin is referred to as the “huffer rash”.Let’s back up to where we assess for hallucinations and take a look at patients who are presenting with hallucinations.

Hallucinations/Anticholinergic8:43–9:32

In this case, first, assess for anticholinergic effects.Here’s a high yield fact! A great way to remember anticholinergic signs and symptoms is by reciting the saying, “red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare, full as a flask”, which refers to flushing; dry mouth and anhidrosis or the inability to sweat; mydriasis; altered mental status; hyperthermia; and urinary retention.If there is no anticholinergic effect, then the exposure is likely due to dextromethorphan or hallucinogens.
Let’s start by discussing exposures to dextromethorphan. These patients often have hyperthermia, flushed skin, agitation, delirium, sedation, nystagmus, slurred speech, ataxia, and hyperreflexia.

Dextromethorphan9:32–10:25

If this is the case, you should consider dextromethorphan intoxication and order urine light chromatography tandem mass spectrometry for dextromethorphan and metabolite.
If positive, diagnose dextromethorphan as the recreational substance exposure.Here’s another high-yield fact! Dextromethorphan use is commonly referred to as “robotripping” because it’s the main ingredient in Robitussin, a common cough suppressant.
At high doses, it can induce phencyclidine-like psychosis with delusions, paranoia, and hallucinations.Okay, now let’s consider a patient who has had exposure to hallucinogens.

Hallucinogens10:25–11:11

This patient reports “seeing” smells and “hearing” colors. Additionally, the physical exam often reveals hyperthermia, flushed skin, euphoria, psychosis, nystagmus, and ataxia.
With these findings, you should consider hallucinogens as the recreational substance exposure and, as a next step, obtain a urine immunoassay for hallucinogens.
Hallucinogens include LSD and mushrooms; as well as MDMA, which can act as both a stimulant and a hallucinogen. If the urine immunoassay is positive for a hallucinogen, diagnose hallucinogens as the recreational substance exposure.Finally, let’s back up and look at patients with hallucinations who also have anticholinergic effects present.

Antihistamines11:11–11:39

In these cases, consider antihistamine toxicity. An easy over-the-counter substance to abuse is diphenhydramine.
As a next step, obtain a urine light chromatography tandem mass spectrometry for antihistamines and, if positive, diagnose antihistamines as the recreational substance exposure.Alright, as a quick recap… Once you suspect a recreational substance exposure, obtain a urine drug screen and a serum ethanol concentration.

Review11:39–12:28

Then, assess the cardiovascular status of the patient to determine the underlying substance. Patients with bradycardia likely have had an exposure to alcohol, opioids, or sedative hypnotics.
On the other hand, patients with tachycardia, who do not have hallucinations, likely were exposed to stimulants, marijuana, or inhalants.
Meanwhile, in patients with tachycardia and hallucinations, you should look for signs of anticholinergic effect. Those without signs of anticholinergic effect likely have had an exposure to dextromethorphan or hallucinogens; while those with anticholinergic effects likely have had exposure to antihistamines.