[Respiratory depression caused by a fentanyl patch applied as a topical analgesic]

Intoxications caused by fentanyl patches are fairly common in emergency departments. Fentanyl extracted from patches may cause intoxications and even deaths in drug abusers due to very high amount of fentanyl in the patches. In the case described by us the cause of intoxication was exceptional, as the patient had placed the patch as topical treatment for shoulder pain. Due to the small and unobtrusive size of the patch and lack of anamnestic information (patient was unconscious) it took five days before the patch was noticed on the patient's skin.