How to manage a tetrahydrocannabinol (THC) overdose in a 4-year-old child?

Management of THC Overdose in a 4-Year-Old Child

THC overdose in a 4-year-old child requires immediate supportive care focused on airway management, monitoring vital signs, and ensuring adequate hydration, as there is no specific antidote for THC toxicity.

Initial Assessment and Management

• Assess airway, breathing, and circulation (ABCs) as the first priority, as THC overdose can cause central nervous system depression and respiratory compromise 1, 2
• Monitor vital signs including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 3, 2
• Evaluate level of consciousness using an age-appropriate scale 2, 4
• Obtain a focused history from caregivers about the type of cannabis product ingested (edible, oil, etc.), approximate amount, time of ingestion, and whether other substances might be involved 2, 5

Clinical Manifestations to Expect

• Central nervous system depression ranging from drowsiness to coma is the most common presentation in pediatric THC overdose 1, 4
• Tachycardia is frequently observed, though bradycardia may occur in severe cases 1, 3
• Respiratory depression requiring ventilatory support in severe cases 2, 4
• Vomiting is common in pediatric cannabis exposures 1, 2
• Ataxia and altered mental status may be present 3, 5
• Seizures are more common in pediatric patients than adults with cannabis toxicity 3, 5

Immediate Interventions

• For respiratory depression, establish a patent airway and provide supplemental oxygen as needed 1
• If severe respiratory depression is present, provide bag-mask ventilation until spontaneous breathing returns 1, 2
• For significantly altered mental status or inability to protect airway, consider endotracheal intubation 2, 4
• Establish intravenous access for fluid administration and medication if needed 2, 5
• Provide isotonic fluid bolus if signs of dehydration are present 1, 2

Diagnostic Considerations

• Obtain urine toxicology screen to confirm THC exposure and rule out other substances 2, 5
• Consider blood glucose measurement to rule out hypoglycemia, which can present similarly 5, 6
• Consider other diagnostic tests based on clinical presentation to rule out alternative diagnoses 5, 6

Ongoing Management

• Provide supportive care with close monitoring of vital signs and neurological status 3, 2
• Monitor for seizures, which are more common in pediatric patients with THC toxicity 3, 5
• Maintain hydration with intravenous fluids if the child is unable to take oral fluids 2, 4
• Observe for at least 6-24 hours depending on severity of symptoms and type of cannabis product ingested (edibles may have delayed and prolonged effects) 2, 4

Disposition

• Admission to a pediatric intensive care unit is warranted for patients with:
  • Significant respiratory depression 2, 4
  • Altered mental status preventing airway protection 2, 4
  • Hemodynamic instability 3, 2
  • Seizures 3, 5
• Consider child protective services notification as pediatric cannabis exposure may indicate neglect or unsafe home environment 5, 6
• Discharge is appropriate when the child returns to baseline mental status, can tolerate oral intake, and has stable vital signs 2, 5

Prevention Counseling

• Before discharge, provide education to caregivers about:
  • Safe storage of cannabis products away from children 1, 6
  • Risks of cannabis products, especially edibles that resemble candy or other child-friendly snacks 1, 6
  • The increasing potency of modern cannabis products and their potential dangers to children 1, 3

Important Caveats

• Unlike opioid overdose, there is no specific antidote for THC toxicity; naloxone will not reverse THC effects 1, 3
• The effects of THC can last much longer in children than adults, particularly with edible products that may have delayed absorption 1, 2
• Children are more susceptible to cannabis toxicity than adults, with higher rates of severe symptoms including seizures and coma 3, 5
• Activated charcoal is generally not recommended as most patients present after the window of effectiveness has passed 2, 6