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Codeine/hydromorphone/morphine Various toxicities: case report

A 13-year-old girl developed opioid poisoning, sickle cell crisis and related complications following an overdose of morphine and misuse of morphine, codeine and hydromorphone [dosages not stated; not all routes stated]. The girl, who had a history of sickle cell disease, was found unresponsive with sonorous respirations at home by her mother. Thereafter, she was transported to an emergency department (ED). It was reported that, her treatment with morphine sulfate [morphine] had been discontinued several months before due to concern of misuse. A day before the ED presentation, she had received an infusion in the haematology clinic and had not been feeling well. On the morning of ED presentation, she had ingested a 25mg diphenhydramine tablet and then had taken a nap around 10AM. As her mother was unable to wake her daughter up until 3PM, emergency medical service was contacted. Upon the arrival of emergency medical service, she was found to have agonal respirations and miosis. She was endotracheally intubated in the prehospital setting for airway protection and hypoxaemia. After the establishment of intraosseous (IO) access, she was transported to a pediatric ED. In the ED, she was unresponsive with a Glasgow Coma Scale (GCS) score of 3T (severe). Subsequent physical examination showed diaphoresis and 1-2mm sluggish pupils. Thereafter, she received naloxone therapy via intraosseous infusion, as she had difficulty with bag-valve ventilation. After the therapy, she immediately awoke, promptly self-extubated and vomited twice while maintaining her airway. Her laboratory test showed abnormal results of haemoglobin (10.5 g/dL), prothrombine time (25.4s), D-dimer (20.00 mg/mL), fibrinogen (129 mg/dL), aspartate aminotransferase (221U/L), alanine aminotransferase (132U/L), creatinine (1.58 mg/dL) and serum lactate (8.9 mmol/L). A primary urine drug analysis detected opiates. A chest radiograph revealed hypoinflated lungs. She again experienced somnolence in the ED. Therefore, naloxone therapy was administered. Following the therapy, she became more arousable, vomited once more, but continued to maintain her airway with a GCS of 11 (moderate). Based on the Naranjo adverse drug reaction probability score (score of 10), opioid poisoning was assessed as ’definite’. Thereafter, she was admitted to the pediatric intensive care unit. On hospital day 1 and day 2, she developed intermittent periods of somnolence requiring naloxone administration with subsequent vomiting. Additionally, she received IV fluids, albumin, ceftriaxone and vancomycin for concerns of sepsis. She also received an exchange transfusion. On day 2 of hospitalisation, she was easily arousable and was breathing comfortably and had normal pupillary examination. A serum expanded toxicology screening of blood showed codeine, hydromorphone and morphine. Subsequent urine analysis showed codeine level of 170 ng/mL, hydromorphone level of 551 ng/mL and morphine level of more than 20000 ng/mL (morphin