This week’s case focused on a child with fluctuating apnea and altered mental status ultimately found to be due to ingestion of marijuana. The diagnostic dilemmas centered on the appropriate respiratory support and decision to perform a lumbar puncture.

The differential for unexplained periodic apnea and AMS is quite broad covering a range of neurological, metabolic, respiratory, and toxicologic conditions. When periodic apnea is present, provider’s should take measures to protect the airway as patients can decompensate rapidly. We discussed that a trial of non-invasive ventilation, which may agitate/stimulate the patient to breathe, could be attempted. However most learners recommended early intubation in the undifferentiated patient. The decision to intubate is always difficult, this case offers a stepwise approach that ultimately spared the patient an intubation however it is important to keep in mind the importance of establishing a stable airway prior to imaging (CT) and invasive procedures like a lumbar puncture.

In this case, the team considered giving Narcan but decided not to as the toxidrome did not fit an opioid overdose. It is important to consider narcan in patient’s with possible ingestions with AMS and apnea as there is relatively low risk and highly therapeutic benefit.

Ultimately the decision to forgo a lumbar puncture was supported by the patient’s improvement in respiratory status and mentation and lack of fever, lowering the suspicion for encephalitis.

Accidental ingestion of marijuana edibles are becoming more prevalent due to their resemblance to everyday snacks and candies. Pediatric ingestion of marijuana edibles can lead to severe symptoms such as altered mental status, respiratory depression, and apnea as seen in this case. This case underlines the importance of continued vigilance for pediatric ingestions and reinforces the need for cautious management of airway stability during diagnostic and therapeutic procedures.