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.