Case report
A 21-year-old female with no significant past medical history was
brought to the emergency department of a tertiary hospital by her
brother due to altered mental status. The brother reported that the
patient had consumed 5 methadone pills prior to becoming unconscious. He
denied any history of methadone use, alcohol abuse, or other substance
abuse. The patient had no known medication allergies, and her medication
history was unremarkable.
Upon arrival to the emergency department, the patient was unconscious
and unresponsive to verbal or painful stimuli. Her vital signs were as
follows: blood pressure 90/60 mmHg, pulse rate 60 beats per minute,
oxygen saturation 90% on room air, respiratory rate 12 breaths per
minute, and a corrected axillary body temperature of 37.2°C. The patient
was immediately placed on supplemental oxygen via a non-rebreather mask
at 10 L/min.
Physical examination revealed an ill-appearing young female without
signs of toxicity, cyanosis, or respiratory distress. Her skin was warm
and dry, with no evidence of needle tracks or other signs of intravenous
drug use. The patient’s head was normocephalic and atraumatic, with no
signs of external injury. Her pupils were equal, round, and pinpoint,
measuring 1 mm in diameter, but they were reactive to light. The
patient’s oral mucosa was moist, and her dentition was intact. No signs
of oral trauma or foreign bodies were observed.
Chest examination revealed a symmetrical chest wall with no deformities
or signs of trauma. The patient’s lungs were clear to auscultation
bilaterally, with no wheezes, crackles, or rhonchi. There were no signs
of accessory muscle use or increased work of breathing. Cardiac
examination revealed a regular rate and rhythm, with no murmurs,
gallops, or rubs. The patient’s abdomen was soft, non-distended, and
non-tender, with no organomegaly or palpable masses. Bowel sounds were
present and normal in all quadrants.
Neurological examination showed the patient to be unresponsive to verbal
or painful stimuli, with a Glasgow Coma Scale score of 3 (E1, V1, M1).
Her muscle tone was flaccid, and deep tendon reflexes were diminished
throughout. No signs of focal neurological deficits or meningeal
irritation were observed.
The patient’s extremities were warm and well-perfused, with no signs of
cyanosis, edema, or trauma. Capillary refill time was less than 2
seconds in all extremities.
Based on the patient’s clinical presentation and the reported history of
methadone ingestion, a preliminary diagnosis of methadone toxicity was
established. Initial management included the administration of
intravenous naloxone, an opioid receptor antagonist, until the patient
regained consciousness. Upon awakening, the patient was immediately
commenced on intravenous fluid resuscitation, and naloxone was
administered intravenously at a dose of 0.4 mg to reverse the effects of
methadone toxicity. The patient’s airway was secured with endotracheal
intubation due to her decreased level of consciousness and risk of
aspiration.
Blood samples were collected for a comprehensive metabolic panel,
complete blood count, arterial blood gas and toxicology screening. The
patient was then admitted to the intensive care unit for close
monitoring and further management of the methadone poisoning. The
laboratory results are summarized in table 1.
Table 1. Summarized laboratory results.