Today's POTD is inspired by The Pitt, and will hopefully be the first in a short series of "Lessons Learned from the Pitt" (LLFTP). For those of you who don't know, The Pitt is a new medical drama on HBO/Max; created by R. Scott Gemmill (producer and writer for ER) and starring Noah Wyle (who also appeared in ER as medical student Carter) as the beleaguered ED chief. The eponymous "Pitt" is Pittsburgh Trauma Medical Center, a single-coverage trauma center in Pittsburgh with beautiful facilities and an allegedly shoestring budget. The season is structured as a single "shift" in the ED, with each episode covering 1 hour of events starting from 7am. The show strives for a higher level of realism and accuracy than other dramas (cough cough Grey's Anatomy), with Noah Wyle stating as well that they intend to showcase various challenges in the US healthcare system that patients and personnel struggle with/against.
Spoilers, obviously.
Episode 1 started off with a few good cases, but today I want to focus on little Tyler, who presents as a "lethargic 4-year-old" with no PMHx, no antecedent illness, no fever, no vomiting, no nuchal rigidity, no skin lesions. Dr. Melissa King also somehow notes "no focal neuro [findings]" on a patient too somnolent to follow any commands. FSBG is 85, and CBC, BMP, UA, and UDS are pending. Her senior resident, Dr. Frank Langdon, comes to the bedside to take his own H&P — specifically asking about possible ingestions, which the parents deny. His exam is brief, first checking for responsiveness and nuchal rigidity followed by auscultating Tyler's heart and lungs and glancing at the monitor. He confidently states "no signs of infection" without having looked under the patient's pajamas or into any cephalic orifices, and walks away.
10 minutes later, they return to reassess Tyler after noting that his CBC and BMP were unremarkable. On re-examination, Dr. Langdon looks in Tyler's mouth and notices remnants of a green gummy. Yep, it's from the stash of pot gummies that mom's brother gave to dad. That's why you gotta be thorough on your physical exam. After security helps defuse the apoplectic mother, Tyler is admitted for monitoring.
The growing decriminalization of marijuana has been followed by a rise in the incidence of accidental cannabis ingestion in children (over tenfold since 2017, with 3054 reported cases in 2021). While children (and especially young children < 5 years old) are notorious for trying to eat anything lying around (including batteries and sometimes cockroaches), this has not been helped by many common THC products coming in forms that are particularly attractive to children — cookies, brownies, gummies, and other confections. Cases are also increasing in severity, with a decrease in the proportion of cases discharged from the ED and an increase in cases requiring admission to the floor and requiring admission to the ICU (1 in 5 admission rate overall).
The most common symptom of cannabis ingestion by far is CNS depression, with tachycardia, vomiting, ataxia, and agitation as distant runner-ups. The toxicity of THC is dose-dependent, and small children eating doses intended for adults will have a commensurately-higher weight-based exposure. Symptoms usually begin by 2 hours post-ingestion. Prolonged toxicity is characterized as having signs or symptoms > 6 hours post-ingestion. Severe toxicity is characterized as the presence of one or more of hemodynamic instability, seizure, myoclonic jerks, severely depressed mental status (responds to noxious stimuli only), agitation requiring sedation, respiratory failure, and/or apnea. In a 2023 Rocky Mountain Poison & Drug Safety study involving a pediatric hospital network, 80 patients were identified in a 7-year period with cannabis ingestions of known THC dose. 74% had prolonged toxicity, and 46 had severe toxicity (with predominantly neurological symptoms). A dose threshold of 1.7 mg/kg THC for severe or prolonged toxicity was proposed based on their data, with each additional 1 mg/kg trebling the risk of severe or prolonged toxicity. It should also be noted that the fraction of patients with known doses was the minor portion, and that severity was not compared between patients with known vs unknown doses of THC. No deaths were reported in this study, nor many other studies, attesting to the efficacy of supportive care.
Cannabis products can regularly contain at least 5mg THC per unit, and over 200mg THC per package. A young child massing 15kg can easily exceed the threshold dose in a single sitting. Some states have risk-reduction laws that require packaging be simple/opaque and not brightly-colored and attractive to children, or that limit the amount of THC that may be contained in one package.
This case teaches us three major lessons:
Consider THC toxicity in the lethargic child who might otherwise be afebrile, well-hydrated, and normoglycemic.
Always look beneath the surface.
Asking about parents' access to drugs, and about specific substances, can help jog their memory.
Other little lessons from Episode 1:
If you have trouble figuring out what language your patient speaks, open up Google Maps. I also polled some laypeople (friends and family) about what they would say if they woke up in a bright strange environment with a bunch of uniformed workers shouting at them in a foreign language, and they unanimously said they'd start shouting the name of their own language.
Recent marathon + malaise + recurrent cardiac arrest = hyperkalemia. Especially with signs like wide QRS and peaked T-waves. Do as Dr. Robby did and don't wait for labs before pushing Ca.
Cardiac pathology may present as upper abdominal pain, don't forget to order the ECG and troponin.
References:
https://pmc.ncbi.nlm.nih.gov/articles/PMC10952774/
https://publications.aap.org/pediatrics/article/151/2/e2022057761/190427/Pediatric-Edible-Cannabis-Exposures-and-Acute
https://www.sciencedirect.com/science/article/abs/pii/S0022347617309393
https://publications.aap.org/pediatrics/article/152/3/e2023061374/193757/Toxic-Tetrahydrocannabinol-THC-Dose-in-Pediatric
https://journals.lww.com/pec-online/abstract/2020/06000/intoxication_from_accidental_marijuana_ingestion.19.aspx
https://link.springer.com/article/10.1007/s13181-021-00849-0