Accidental methadone intoxication masquerading as asthma exacerbation with respiratory arrest in a six-year-old boy

A 6-year-old boy is brought to the emergency department of a level 1 trauma center by emergency medical services (EMS) for presumed asthma exacerbation with subsequent unresponsiveness and transient bradycardia. The initial physician exam was remarkable for an unresponsive child, with diffusely diminished breath sounds bilaterally, accompanied by diffuse wheezing, as well as pinpoint pupils. This last observation led to the recommendation to attempt a dose of naloxone for a possible overdose prior to proceeding with intubation for the altered mental status. The child had a brisk response to the naloxone, was subsequently placed on a naloxone drip, and admitted to the hospital. Initial provider thoughts were that the naloxone had worked on an accidental overdose of over-the-counter dextromethorphan containing medication. These suspicions were later proven incorrect after mass spectrometry yielded a positive methadone presence in the urine. The child was ultimately discharged home with ongoing input from child protective services, without further medical complications. The increased utilization of methadone for the treatment of both opioid withdrawal, as well as for chronic pain management demands, heightened awareness of the clinicians, as cases such as this will continue to appear.