Synthetic Drug Intoxication in Children: Recognition and Management in the Emergency Department

When children and adolescents present to the emergency department with agitation or mental status changes, intoxication from synthetic drug use should be in the differential diagnosis. Identifying the responsible compound(s) may be difficult, so asking the patient broad questions and utilizing appropriate diagnostic studies, when indicated, will aid in making the diagnosis and help identify more-serious complications. This issue discusses the challenges presented by the changing chemical formulations of synthetic cannabinoids, cathinones, and phenethylamines; outlines common presentations of intoxication from these substances; and summarizes best practices for evaluating and managing patients who present with intoxication after consumption of these synthetic drugs of abuse.

A 15-year-old girl presents to your ED at 3 AM. She is brought in by her mother, who woke up and found the girl staggering around their living room. The patient’s electronic medical record is unremarkable; the girl has no significant past medical history. On examination, she is mildly tachycardic; injected conjunctiva and diaphoresis are noted. The girl laughs intermittently and inappropriately during your encounter. Upon further discussion, she admits smoking marijuana that was purchased on the Internet by an older sibling. Several hours later, her mentation improves, but she now reports 6 out of 10 chest pain. What other substances could have been combined with the “marijuana?” Will blood or urine testing lead to a diagnosis? Is any management beyond supportive care indicated for this patient?