Here we present the case of a 14-year-old female who presented
to our community emergency department after reportedly
ingesting about 30 tablets of an unknown medication while at
school about 2 hours prior to arrival. She denies suicidal ideation,
gestures, plan or attempt (although she admitted a history
of suicide attempts); stating she took it for relief of knee
pain. The medication was her friend’s. She reported malaise,
nausea, dry mouth, blurry vision, jitteriness, and dyspnea; denying
any other systemic complaints, including vomiting of pill
fragment, chest or abdominal pain, diarrhea, headaches, syncope,
light-headedness, or diaphoresis.
She had no medical or surgical history, and denied drug or
food allergies. She took no medications on a daily basis, and
all immunizations were up-to-date. The patient admitted to
smoking marijuana once within the past month; no other illicit
drug intake, as well as no alcohol or tobacco products.
Given her significant presentation, she was dispositioned as ESI
level 1 (emergency severity index, on a scale from 1 to 5, with
a lower number representing higher acuity). Initial vital signs
were as follows: blood pressure 105/54 mmHg, pulse rate of
130 beats per minute and regular, respirations of 14 breath per
minute, saturating 100% on ambient air, and axillary temperature
of 98.8 Fahrenheit. On examination, she was somnolent
but arousable to loud verbal as well as noxious stimuli; Glasgow
Coma Scale 14. On physical examination, she appeared toxic
and uncomfortable. Neurologic exam including speech and
mentation were intact, aside from her eyes which were 3 mm
bilaterally, not reactive to light and exhibited roving movement.
Cardiopulmonary exam was insignificant aside from the tachycardia
as noted. Skin was not diaphoretic, of normal colour and
without piloerection. She weighed 52 kg (BMI: 19).
A work-up was immediately undertaken focusing on suspected
overdose, inflammatory and cardiac markers. Lactate was 3.7
mmol/L (reference range: <2.2). Arterial pH 7.34. Remaining
bloodwork, including electrolytes, blood counts, liver/kidney/
pancreas functions, cardiac biomarkers, coagulation studies,
osmolality, urinalysis, urine drug screen, alcohol, and salicylate
levels were unremarkable. Her urine pregnancy was negative.
A portable plain chest film was without an acute process.
An electrocardiogram done upon initial presentation and repeated
about 3 hours later both revealed sinus tachycardia in
the 120-130 beats per minute, with normal axis and intervals
(QRS 84 and 110 milliseconds, QTc 457 and 489 milliseconds,
respectively), without an acute current of injury.
Intravenous fluids in the form of normal saline were ordered
as well as lorazepam for agitation. Naloxone was also
attempted for somnolence without a response. Despite a
weight-based dose for fluid resuscitation, her blood pressure
was 84/57 mmHg; she remained tachycardic in the 120s, vital
signs otherwise were stable. A central line was placed and Dopamine
initiated.
Anticholinergic overdose was briefly entertained, although
her clinical presentation did not completely align with the
familiar toxidrome. More information was soon available
when the patient’s parents arrived: the mother strongly suspected
she took Motrin from one of her friends, estimated to
be about 18 grams (30 tablets, 600 mg each). It was also discovered
she was taking oral contraceptives, valacyclovir, and
was on a course of ciprofloxacin for cystitis. Pantoprazole was
added intravenously.
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