Q 1:
A worried grandmother brings her 2-year-old grandchild to the emergency department immediately upon finding the boy with an open bottle of 81-mg chewable aspirin (which is used by the grandfather for coronary artery disease prophylaxis). She is unsure of the number of tablets in the bottle prior to ingestion, but the original number was 30, and there are now three remaining. The child has vomited once and is fussy and lethargic. Physical evaluation reveals a 12-kg child who has tachypnea and tachycardia. Laboratory results include a pH of 7.45, carbon dioxide of 25 mEq/L (25 mmol/L), and bicarbonate of 18 mEq/L (18 mmol/L). A salicylate measurement result is pending.
Of the following, the next BEST step in the management of this child is to
A. administer activated charcoal
B. administer sodium bicarbonate intravenously
C. administer syrup of ipecac
D. observe the child clinically in the emergency department
E. remeasure the salicylate level in 6 hours
The Answer :
A
Explanation :
The next best step in the management of the child described in the vignette is the administration of activated charcoal. Multiple doses of activated charcoal adsorb salicylates from both the intestinal tract and the systemic circulation.
For a child who has ingested a potentially toxic dose of salicylates, serum salicylate concentrations should be measured 2 to 6 hours after the ingestion.
However, administration of activated charcoal should not be delayed until the salicylate concentration has been measured if a toxic dose has been ingested.
The child in the vignette may have ingested 27 81-mg tablets for a total dose of more than 2,100 mg or 182 mg/kg. This dose can be expected to cause mild-tomoderate toxicity.
A serum salicylate value higher than 30 mg/dL is considered toxic, concentrations higher than 70 mg/dL reflect severe toxicity, and those greater than 100 mg/dL are life-threatening.
Because gastric emptying time is prolonged with salicylate ingestion, gastrointestinal decontamination by lavage may be effective up to 6 hours after ingestion. However, the child described in the vignette is fussy and lethargic. Therefore, syrup of ipecac is not indicated.
Administration of sodium bicarbonate to alkalinize the urine as well as correction of acidosis,
hyperkalemia, and hypocalcemia are important adjuncts to gastric decontamination.
---------------------
Q 2:
A 5-year-old boy presents to the emergency department 30 minutes after he ingested some of his mother’s tricyclic antidepressant. Over the ensuing hour of observation in the emergency department, he develops lethargy, irritability, and autonomic nervous system findings of mydriasis, dry mouth, and urinary retention. Within 3 hours of ingestion, these symptoms have resolved.
Of the following, the MOST appropriate next step in management is
A. chest radiography and arterial blood gas
B. discharge home without further evaluation
C. electrocardiography and continuous cardiac monitoring
D. serum electrolytes assessment
E. tricyclic serum drug concentration assessment and discharge home
Answer :
C
An overdose of any of the tricyclic antidepressant drugs may result in a fatal cardiac dysrhythmia.
Often, the effect on the heart is delayed; presentation to the emergency department with various other
signs and symptoms may precede the cardiac findings.
Such earlier features may include lethargy, irritability, anticholinergic effects upon the autonomic nervous system associated with sympatheticnervous system dysfunction, and seizures.
Anticholinergic effects of tricyclic antidepressants include dry mouth, blurred vision, tachycardia, urinary retention, constipation, dizziness, and vomiting.
The cardiac toxicity associated with this class of agents most often manifests as a prolongation of the QRS complex on electrocardiographic monitoring.
Therefore, the boy described in the vignette should receive electrocardiography and continuous cardiac monitoring. In addition, atrioventricular block can occur, and prolongation of the PR interval (first-degree heart block) is common.
The QRS complex prolongation is caused by delayed conduction through a poisoned myocardium.
As toxic effects on the myocardium worsen, loss of cardiac mechanical activity and severely widened QRS complexes occur simultaneously.
Ventricular tachyarrhythmias are a common late finding. Electromechanical dissociation (EMD) can result, leading to the need for urgent cardiopulmonary resuscitation.
EMD does not respond to electrical cardioversion, instead requiring cardiac support with extracorporeal membrane oxygenation or some other form of ventricular assist device. If there is metabolic acidosis, infusion of sodium bicarbonate is appropriate.
Two mechanisms are postulated for its therapeutic effect. Tricyclic antidepressants are
protein-bound and become less bound in more acidic conditions. By reversing the acidosis, protein
binding increases and bioavailability decreases. An alternative explanation is that the sodium load helps
to reverse the sodium channel-blocking effects of the tricyclic antidepressants. Treatment is otherwise
supportive.
Respiratory depression can result from the central nervous system sedative properties of these
agents, and if present, warrants careful laboratory and clinical observation. However, these findings do
not appear late, and this boy has no indication of respiratory compromise.
Discharging the boy after 3 hours of observation in the emergency department is not appropriate, given the potential for late cardiac ffects.
Although serum electrolyte imbalance could exacerbate any ventricular dysrhythmia, tricyclic antidepressant toxicity does not directly affect serum electrolyte concentrations or renal function.
The tricyclic antidepressants are highly metabolized by the cytochrome P450 hepatic enzymes.
Measuringserum concentrations of the tricyclic antidepressants may be useful in assessing the potential for toxicity, but such findings alone should not lend reassurance when early noncardiac symptoms are present. In this situation, further inpatient monitoring is always indicated.
----------------------------
Q 2:
Answer :
B
The unresponsive, hypothermic, hypotensive boy in the vignette, who also has respiratory depression and miosis, most likely has ingested an overdose of barbiturates, opiates, or other sedative/hypnotics.
Although an overdose of amphetamines, cocaine, LSD, or phencyclidine could produce coma, findings on physical examination differ significantly from those of barbiturate intoxication. Patients intoxicated with any of these substances generally have tachycardia, hypertension, hyperthermia, and dilated pupils
----
Q 3:
Answer :
C
---------------------
Q 2:
A 5-year-old boy presents to the emergency department 30 minutes after he ingested some of his mother’s tricyclic antidepressant. Over the ensuing hour of observation in the emergency department, he develops lethargy, irritability, and autonomic nervous system findings of mydriasis, dry mouth, and urinary retention. Within 3 hours of ingestion, these symptoms have resolved.
Of the following, the MOST appropriate next step in management is
A. chest radiography and arterial blood gas
B. discharge home without further evaluation
C. electrocardiography and continuous cardiac monitoring
D. serum electrolytes assessment
E. tricyclic serum drug concentration assessment and discharge home
Answer :
C
An overdose of any of the tricyclic antidepressant drugs may result in a fatal cardiac dysrhythmia.
Often, the effect on the heart is delayed; presentation to the emergency department with various other
signs and symptoms may precede the cardiac findings.
Such earlier features may include lethargy, irritability, anticholinergic effects upon the autonomic nervous system associated with sympatheticnervous system dysfunction, and seizures.
Anticholinergic effects of tricyclic antidepressants include dry mouth, blurred vision, tachycardia, urinary retention, constipation, dizziness, and vomiting.
The cardiac toxicity associated with this class of agents most often manifests as a prolongation of the QRS complex on electrocardiographic monitoring.
Therefore, the boy described in the vignette should receive electrocardiography and continuous cardiac monitoring. In addition, atrioventricular block can occur, and prolongation of the PR interval (first-degree heart block) is common.
The QRS complex prolongation is caused by delayed conduction through a poisoned myocardium.
As toxic effects on the myocardium worsen, loss of cardiac mechanical activity and severely widened QRS complexes occur simultaneously.
Ventricular tachyarrhythmias are a common late finding. Electromechanical dissociation (EMD) can result, leading to the need for urgent cardiopulmonary resuscitation.
EMD does not respond to electrical cardioversion, instead requiring cardiac support with extracorporeal membrane oxygenation or some other form of ventricular assist device. If there is metabolic acidosis, infusion of sodium bicarbonate is appropriate.
Two mechanisms are postulated for its therapeutic effect. Tricyclic antidepressants are
protein-bound and become less bound in more acidic conditions. By reversing the acidosis, protein
binding increases and bioavailability decreases. An alternative explanation is that the sodium load helps
to reverse the sodium channel-blocking effects of the tricyclic antidepressants. Treatment is otherwise
supportive.
Respiratory depression can result from the central nervous system sedative properties of these
agents, and if present, warrants careful laboratory and clinical observation. However, these findings do
not appear late, and this boy has no indication of respiratory compromise.
Discharging the boy after 3 hours of observation in the emergency department is not appropriate, given the potential for late cardiac ffects.
Although serum electrolyte imbalance could exacerbate any ventricular dysrhythmia, tricyclic antidepressant toxicity does not directly affect serum electrolyte concentrations or renal function.
The tricyclic antidepressants are highly metabolized by the cytochrome P450 hepatic enzymes.
Measuringserum concentrations of the tricyclic antidepressants may be useful in assessing the potential for toxicity, but such findings alone should not lend reassurance when early noncardiac symptoms are present. In this situation, further inpatient monitoring is always indicated.
----------------------------
Q 2:
A
12-year-old boy is brought to the emergency department after having been found
unresponsive. On physical examination, he is comatose and has the
following vital signs: respiratory rate, 10 breaths/min; heart rate, 64
beats/min; blood pressure, 96/50 mm Hg; and temperature, 97°F (36.1°C). His
pupils are miotic. Of
the following, these findings are MOST suggestive of:
A. amphetamine
overdose
B. barbiturate
overdose
C. cocaine
overdose
D. lysergic
acid diethylamide (LSD) ingestion
E. phencyclidine
ingestion
Answer :
B
The unresponsive, hypothermic, hypotensive boy in the vignette, who also has respiratory depression and miosis, most likely has ingested an overdose of barbiturates, opiates, or other sedative/hypnotics.
Although an overdose of amphetamines, cocaine, LSD, or phencyclidine could produce coma, findings on physical examination differ significantly from those of barbiturate intoxication. Patients intoxicated with any of these substances generally have tachycardia, hypertension, hyperthermia, and dilated pupils
----
Q 3:
A
4-year-old child is brought by ambulance to the emergency department. He is
unconscious and has deep, regular, and rapid respirations.
A
clinical finding that BEST distinguishes this respiratory pattern as central
hyperventilation rather than tachypnea is:
A. arterial
carbon dioxide pressure (Paco2) of 26 mm Hg
B. decreased
mental status
C. nonreactive
pupils
D. oxygen
saturation of 95% by pulse oximetry
E. sternal
retractions
.Answer :
C
Central
hyperventilation, characterized by sustained, rapid, and fairly deep hyperpnea,
differs from the rapid, shallow respirations of simple tachypnea. Central
hyperventilation typically represents one sign in the stages of coma that
result from markedly elevated intracranial pressure and progression toward
transtentorial or uncal herniation (Figure 25A). The earliest signs are
decreased level of consciousness and alterations in the respiratory pattern.
Patients who have central hyperventilation may have hypertension and
bradycardia (Cushing triad).
During
the systematic stages of coma, specific signs develop as injury progresses
inferiorly along the brainstem. Initially, in the low diencephalic stage, the
child is comatose, has Cheyne-Stokes respirations (crescendo-decrescendo
hyperventilation to apnea), small and sluggishly reactive pupils, doll’s eyes
(oculocephalic) and caloric (oculovestibular) reflexes, and decorticate
(flexion of the upper extremities and extension of the lower extremities)
response to pain. Later, at the midbrain stage, the respiratory pattern changes
to sustained central hyperventilation, the pupils become midposition and fixed,
and there is a stereotyped decerebrate (extensor with all extremities)
posturing to noxious stimuli. At the pontine stage, hyperventilation gives way
to apneustic breathing (deep respirations with prolonged pauses), the pupils are
small-to-pinpoint and nonreactive, and caloric and doll’s eyes reflexes may be
absent. Finally, the extremities become flaccid with absent motor response,
breathing becomes ataxic, and death ensues.
Decreased
oxygen saturation and diminished mental status are nonspecific findings that
can characterize many processes other than central hyperventilation, such as
hypoxia secondary to pulmonary disease. A decreased arterial carbon dioxide
pressure can be seen in hyperventilation attacks or psychogenic hyperventilation
as well as central hyperventilation. Sternal retractions are typical of hypoxia
in patients who have lower airway disease and are not a feature of central
hyperventilation.
Loss
of pupillary response is typical for a midbrain or pontine brainstem process
and, combined with loss of consciousness, should alert the clinician to the
possibility of impending uncal herniation. Other causes for bilateral loss of
pupillary reflex (eg, pilocarpine drops, opiates, atropine drops, cocaine, and
jimson weed) should be considered only after the possibility of increased
intracranial pressure has been excluded.
-----------------------
Q 3:
-----------------------
Q 3:
A
3-year-old boy was found with an open bottle of imipramine. At least five 50 mg
tablets were missing. In the emergency department almost 2 hours after the
discovery, he is alert and has normal vital signs.
Of
the following, the MOST appropriate initial management is electrocardiographic
monitoring and:
A. administration
of activated charcoal with sorbitol
B. administration
of syrup of ipecac and observation
C. administration
of syrup of ipecac followed by charcoal
D. gastric
lavage
E. whole
bowel irrigation
Answer :
A
Answer :
A
Activated
charcoal effectively absorbs many toxins and drugs, preventing systemic
absorption. It is the treatment of choice for gastrointestinal decontamination,
especially for patients who present more than 2 hours after ingestion. However,
it is not used for the management of poisonings involving heavy metals, iron,
lithium, hydrocarbons, methanol (found in windshield washer fluid), and
ethylene glycol (found in antifreeze) because these substances do not bind to
charcoal. An intestinal obstruction or ileus also is a contraindication to the
use of activated charcoal.
A
cathartic may be added to the first dose of activated charcoal to hasten
transit and elimination of the bound toxin. Sorbitol, magnesium sulfate, and
magnesium citrate are commonly available cathartics. However, cathartics such
as sorbitol, when used in young children, require monitoring of the patient for
development of dehydration and electrolyte imbalances. Magnesium-containing cathartics
also are contraindicated in patients of any age who have decreased renal
function.
Inducing
emesis with syrup of ipecac is an inefficient method of gastrointestinal
decontamination, especially 2 hours or more after ingestion, and is
contraindicated for poisonings that have a potential to cause central nervous
system depression. It is also contraindicated in infants younger than 6 months
of age and in the treatment of caustic and hydrocarbon ingestions. The
usefulness of gastric lavage in young children is limited by the need to use a
relatively small-bore tube. Activated charcoal is more efficient and
efficacious.
Whole
bowel irrigation uses a polyethylene glycol solution to flush the
gastrointestinal tract. It has been useful in poisonings involving toxins or
drugs that do not bind to charcoal and sustained- or delayed-release drug
preparations. This procedure must be used cautiously in young children, who are
at risk for fluid and electrolyte complications.
------------------
Q4 :
------------------
Q4 :
The
most likely finding in the initial stages of septic shock is:
A. abnormally
low blood pressure
B. absent
femoral pulses
C. delayed
capillary refill
D. hyperpnea
E. tachypnea
Answer :
C
Answer :
C
Shock
is a state of inadequate delivery of oxygenated blood flow to the body’s organs
relative to the demands of those organs. Ischemia is lack of normal blood flow.
Hypoxemia is abnormally low oxygen tension in the blood. The combination of
hypoxemia and ischemia is most detrimental, resulting in irreversible damage to
organs and if not corrected, resulting in death.
Pure
hypoxemia without ischemia can be tolerated well, especially if it develops
chronically. An example of this principle is the sometimes surprisingly healthy
status and normal mental development of children who have partially repaired
cyanotic heart disease. Children who have single ventricle physiology, such as
hypoplastic left heart syndrome, may await completion of the Fontan repair for
several years. During that time, the systemic oxygen saturation may be less
than 80%, but there is normal blood flow to the body’s organs and no untoward
symptoms other than lower-than-normal exercise tolerance.
Conversely,
a myocardial infarction or stroke causes damage to the heart or brain from the
sudden lack of blood flow to the tissues. Appreciated but not completely
understood is the importance of the role of blood flow in washing out toxic
metabolites from cells, a function independent from oxygen delivery.
In
pediatric practice, the most common causes of shock are severe dehydration and
overwhelming sepsis. Hypotension and increased metabolic demand combine to
produce inadequate tissue blood flow, with the development of metabolic
acidosis that can end in death. Therefore, early clinical recognition of shock
is vitally important.
Studies
show that cardiac output may be compromised significantly before any clinically
significant fall in blood pressure becomes apparent. Accordingly, hypotension
and absent femoral pulses are late findings of shock. Hyperpnea (deep
respirations) and tachypnea (rapid respirations) occur in shock, especially as
metabolic acidosis develops when perfusion of the kidneys and other organs
falls to critically low levels. However, these findings usually are not the
earliest clinical signs of inadequate tissue perfusion.
The
flush of pink color into the finger tips or toes following release of gentle
pressure on the digit (capillary refill) provides a direct view of the arterial
filling of the distal extremities. The speed and vigor with which capillary
refill occurs is a good early warning system in the child or infant in whom
shock may develop. Delayed capillary refill (>3 sec) is an early sign of
shock. Serial assessments of this physical sign should be as routine and
frequent as vital signs in all seriously ill hospitalized infants and children.
----
Q 5
Upper endoscopy under general anesthesia should be performed within the first 48 hours of caustic ingestion to determine the extent of the esophageal injury. The objective of the endoscopy is to establish the presence or absence of an esophageal lesion and to determine the extent of the injury
----
Q 5
A
5-year-old boy is given general anesthesia with halothane for a tonsillectomy
and adenoidectomy. Shortly after initiating the procedure, he develops
tachycardia, a temperature of 103°F (39.4°C), and muscle rigidity.
Of
the following, the MOST appropriate definitive treatment includes
discontinuation of anesthetic and treatment with:
A. acetaminophen
B. dantrolene
C. dapsone
D. hydrocortisone
E. succinylcholine
Answer
B
Malignant
hyperthermia (MH) is a rare, life-threatening complication of general
anesthesia. It is characterized by tachypnea, tachycardia, hypermetabolism,
muscle rigidity, hypercarbia, acidosis, and fever that can occur following
exposure to inhalational anesthetics such as halothane, isoflurane, or a
depolarizing muscle relaxer such as succinylcholine. The potential to develop
MH is inherited in an autosomal dominant pattern with variable penetrance.
Because of this, a family history of anesthesia-associated complications should
be sought prior to surgery. It is more common among patients who have a variety
of myopathic disorders, including Duchenne muscular dystrophy.
Initial
indications of MH during general anesthesia may be tachycardia, tachypnea,
fever, or any of the other symptoms mentioned previously. Monitoring
temperature and cardiovascular stability during general anesthesia is essential
to identify and allow for early treatment of this complication.
Treatment
includes cessation of triggering anesthetic agents, hyperventilation with
oxygen, and administration of dantrolene 3 mg/kg intravenously to a total
loading dose of 10 mg/kg, if necessary. Dantrolene works directly on skeletal
muscle, causing excitation-contraction coupling dissociation by interfering
with the release of calcium from the sarcoplasmic reticulum. Circulatory
support, treatment of hyperkalemia and acidosis, active cooling measures, and
urinary alkalinization to prevent tubular injury from severe rhabdomyolysis
also are appropriate.
If
subsequent procedures must be performed under general anesthetic, nontriggering
anesthetics that may be used safely include barbiturates, opioids, propofol,
nitrous oxide, benzodiazepines, and nondepolarizing muscle relaxers. Local
anesthetics also represent safe alternatives.
Administration
of acetaminophen for fever is an appropriate adjunctive measure when MH is diagnosed,
but treating only the fever will not prevent the life-threatening consequences.
Dapsone may be used in the treatment of a variety of disorders, including
dermatitis herpetiformis and leprosy, and for malaria prophylaxis.
Hydrocortisone should be considered for the treatment of a suspected allergic
reaction, but such a reaction should not manifest with fever or muscle
rigidity. Because it is a likely triggering agent for MH, succinylcholine is
contraindicated.
------------------------------
Q 6
Q 6
A
2-year-old infant is brought to the emergency department after his mother found
him drinking an unknown substance from a soda bottle in the family's pool
house. You suspect that the substance was an acidic pool cleaner. Physical
examination of the child's lips, tongue, and oropharynx reveals no
abnormalities.
Of
the following, the MOST appropriate next step in management is:
A. emergent
upper gastrointestinal radiographic series
B. initiation
of oral antibiotic therapy
C. parental
reassurance and patient discharge
D. placement
of a nasogastric tube for lavage
E. referral
for emergent esophagoscopy
Answer
E
Answer
E
Upper endoscopy under general anesthesia should be performed within the first 48 hours of caustic ingestion to determine the extent of the esophageal injury. The objective of the endoscopy is to establish the presence or absence of an esophageal lesion and to determine the extent of the injury
---
Q 7
.
Of
the following, the MOST appropriate next diagnostic study is:
A. abdominal
computed tomography
B. abdominal
ultrasonography
C. barium
contrast enema
D. diagnostic
peritoneal lavage
E. upright
plain abdominal film
Answer
A
Answer
A
If
abdominal trauma is suspected, as suggested for the child described in the
vignette, the imaging modality of choice in a pediatric patient is computed
tomography, usually with at least double contrast (oral and intravenous).
Laboratory tests may include a complete blood count, type and crossmatch, blood
gas determination, urinalysis, and chemistries that include serum amylase. The
role of abdominal ultrasonography in the pediatric patient has not yet been
established, although its use has become common in adults. Although a film of
the pelvis often is warranted to assess for pelvic fractures, an upright
abdominal film generally is neither helpful nor practical. Diagnostic
peritoneal lavage has little role in pediatric trauma unless the patient is
hemodynamically unstable. Easy access to rapid computed tomography has made
this a rare procedure. A barium contrast enema is rarely, if ever, indicated.
------
Q 8
------
Q 8
A
13-year-old boy is brought to the emergency department after having been found
unresponsive at a party. On physical examination, he is comatose and has the
following vital signs: respiratory rate, 10 breaths/min; heart rate, 64
beats/min; blood pressure, 96/50 mm Hg; and temperature, 97°F (36.1°C). His
pupils are miotic.
Of
the following, these findings are MOST suggestive of:
A. amphetamine
overdose
B. barbiturate
overdose
C. cocaine
overdose
D. lysergic
acid diethylamide (LSD) ingestion
E. phencyclidine
ingestion
Answer
B
Answer
E
Any febrile child with diffuse, raised purpuric rashshould be considred due to meningococcemia unless proven otherwise.
--
Q10:
Answer
D
The combination of visual hallucinations, anxiety, panic, and depression are suggestive of use of a hallucinogen, such as lysergic acid diethylamide (LSD).
Intoxication with barbiturates, benzodiazepines, ethanol, or opiates produces sedation, not agitation, and is not associated with hallucinations. Furthermore, depressants (eg, barbiturates, benzodiazepines) and opiates cause miotic pupils, decreased body temperature, and decreased blood pressure, not signs of sympathetic stimulation, as seen in this boy in the vignette.
Answer
B
All
barbiturates are potentially addictive and may cause an abstinence syndrome
when discontinued. A daily dose of 600 mg to 800 mg of a short-acting
barbiturate for 1 month or more will cause physiologic dependence. Higher doses
create a stronger dependence and more serious abstinence symptoms. Within 24
hours of discontinuing a short-acting barbiturate, an addicted individual
experiences withdrawal symptoms such as weakness, tremors, sweating, insomnia,
agitation, delusions, psychosis, seizures, and hyperthermia.
Although
an overdose of amphetamines, cocaine, LSD, or phencyclidine could produce coma,
findings on physical examination differ significantly from those of barbiturate
intoxication. Patients intoxicated with any of these substances generally have
tachycardia, hypertension, hyperthermia, and dilated pupils.
---------------
Q 9
---------------
Q 9
A
4-year-old girl developed a fever to 104°F (40°C) and a diffuse, raised
purpuric rash this morning. Laboratory studies reveal: white blood cell count,
5,100/cu mm (5.1 x 109/L); hemoglobin, 11.8 g/dL (118 g/L); platelets, 189 x
103/cu mm (189 x 109/L); prothrombin time, 11.8 sec; partial thromboplastin
time, 28 sec; and fibrinogen, 250 mg/dL (2.5 g/L).
Of
the following, the MOST likely etiology of the purpura is:
A. disseminated
intravascular coagulation
B. Henoch-Schönlein
purpura
C. hereditary
telangiectasia
D. inherited
platelet dysfunction
E. meningococcemia
Answer
E
Any febrile child with diffuse, raised purpuric rashshould be considred due to meningococcemia unless proven otherwise.
--
Q10:
A
12-year-old boy is brought to the emergency department after a party. He has
dilated pupils, conjunctival injection, and visual hallucinations. In addition,
he is anxious and agitated and has feelings of panic and depression.
Of
the following, these findings are MOST consistent with ingestion of:
A. barbiturates
B. benzodiazepines
C. ethanol
D. lysergic
acid diethylamide (LSD)
E. opiates
Answer
D
The combination of visual hallucinations, anxiety, panic, and depression are suggestive of use of a hallucinogen, such as lysergic acid diethylamide (LSD).
Intoxication with barbiturates, benzodiazepines, ethanol, or opiates produces sedation, not agitation, and is not associated with hallucinations. Furthermore, depressants (eg, barbiturates, benzodiazepines) and opiates cause miotic pupils, decreased body temperature, and decreased blood pressure, not signs of sympathetic stimulation, as seen in this boy in the vignette.
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