A 2-year-old girl presented to the emergency department with lethargy and possible seizure activity after opioid overdose. CT scan showed symmetric low attenuation in the white matter and cerebellum with minimal effacement of cisterns. Naloxone was ineffective and urine toxicology was positive for opioids. Pulmonary edema can occur hours after revival with naloxone due to inadequate respiratory assistance and is a major risk for any respiratory emergency patient. Neurosurgical intervention may be required for opioid-induced acute cerebellitis presenting with hydrocephalus and cerebellar edema.

1. Journal of Neurosurgery: Pediatrics
Dec 2015 / Vol. 16 / No. 6 / Pages 752-757
Opioid overdose in a child: case report and discussion with emphasis
on neurosurgical implications
 Andrew Reisner, MD, Laura L. Hayes, MD, Christopher M. Holland, MD, PhD,
David M. Wrubel, MD, Meysam A. Kebriaei, MD, Robert J. Geller, MD, Griffin R.
Baum, MD, and Joshua J. Chern, MD, PhD
OPIATES are drugs derived from opium, and opioids are synthetic narcotics that have opiate-like
actions.24 Opioid overdose in children is usually related to access to pain medication or illicit drugs
used by someone else in the household.4,23 Most of the morbidity and mortality attributable to opioid
use occurs after acute ingestion.4,13,31 In particular, hypoxia, anaphylaxis, pulmonary edema, acute
respiratory acidosis, and aspiration pneumonitis are life-threatening complications of opioid overdose
demanding urgent attention.11,31 The use of naloxone and physiological support are often sufficient
to result in full recovery.2,3,5,13,20,34 However, both immediate and delayed effects of opioid overdose
can potentially result in severe neurological complications related to hypoxia and the direct toxic
insult introduced by the drug.9,10 Prompt diagnosis and treatment are mandatory for successful
outcomes in these patients. Often, as in this case, the radiological features are highly suggestive, if
not pathognomonic, of the diagnosis prior to toxicological confirmation.4,21,31,37 In cases in which
there is opioid induced acute cerebellitis, neurosurgical intervention may be required in the form of a
ventriculostomy and/or suboccipital decompressive craniectomy for acute hydrocephalus and
cerebellar edema with herniation, respectively. This report specifically highlights the neurosurgeon’s
role in diagnosing and treating children with opiate-induced acute cerebellitis.
Case Report
Initial Presentation and Management
A 2-year-old girl with no significant medical history presented to the
emergency department with lethargy and possible seizure activity. At
presentation, her initial neurological examination was consistent with a
Glasgow Coma Scale score of 4. She was resuscitated and intubated
[rescue breathing for lay responder] for airway protection. An emergency
noncontrast CT scan of the head revealed symmetric low attenuation in the
white matter of the cerebrum and cerebellarhemispheres and effacementof
the prepontine cistern (Fig. 1). There was minimal effacementof the basilar
cisterns and fourth ventricle without significant hydrocephalus. Naloxone
was administered without effect. A urine toxicology screen was positive for
opiates. [kept alive with rescue breathing only, naloxone ineffective]

3. NALOXONEINEFFECTIVERESCUEBREATHING ESSENTIALAT ONSETOF RESPIRATORY
DEPRESSION TO AVOIDCOMPLICATIONSHYPOXIA

6. PULMONARY EDEMA CAN HAPPEN HOURS AFTER PATIENTHASBEEN
REVIVEDWITH NALOXONE.CAUSEINADEQUATERESPIRATORYASSIST
PULMONARY EDEMA ISA KILLER TO ANY RESPIRATORYEMERGENCY PATIENT

11. Reference hyperlinks opioid overdose
https://aliascpr.wordpress.com/2015/12/13/2015-ilcor-and-aha-
references-opioid-od/ https://jgarythompson.wordpress.com/
Poisons (drugs) did not magically change their chemical structure and
start causing death by cardiac arrest. Any poisoning drug OD is a
respiratory emergency. Our diaphragm still controls our breathing,
adult needs 1.5 liters of air every 5 seconds. Naloxone is second line
defense because it does not always work and every second you
withhold the air from any respiratory patient every cell, tissue and
organ is dying lack of oxygen, especially the brain. Note massive
doses Naloxone used, and continuous respiratory assist. Rescue
breathing lay responder same.