Background: Topical compounded pain creams are gaining popularity as a treatment for neuropathic pain. Compounding allows the medication to be customized to individual patient’s needs. Often individual ingredients are listed as abbreviations on the label, which may lead to confusion and delayed treatment when dealing with unplanned exposures. We present a case of dermal exposure of such a product in a child that resulted in CNS and respiratory depression requiring mechanical ventilation. Case report: A 2-year-old girl was playing with her mother’s compounded topical pain cream and rubbed the cream all over her face. Parents insisted that she did not ingest any and promptly washed her face with soap and water. Poison Control was contacted 20min post-exposure with the girl already in the ED. At that time she was drowsy. The girl’s mother brought the prescription, however, she was unaware of what the abbreviations on the label meant. The label read as c-pgb 2.5/kea 10/gab 8/cl 0.3. It was initially suspected that the cream contained a combination of gabapentin, pregabalin, clonidine, and an NSAID. Initial vital signs: BP 152/97, HR 102, SpO2 90%. Shortly after ED arrival she became apneic and was intubated. Through contacting the compounding pharmacy it was determined that the cream contained ketamine, not an NSAID. The girl was extubated and discharged home within 24 h from the time of exposure. Discussion: The prescription was confirmed by the compounding pharmacy to contain pregabalin 2.5% (w/v), ketamine 10%, gabapentin 8% and clonidine 0.3%. All these medications have the potential to cause significant CNS depression, though we believe ketamine is the primary culprit as the patient did not experience bradycardia or hypotension. The maximum sedation dose for ketamine is 10 mg/kg, which would be as little as 1mL of a 10% product for a 10 kg child. Ketamine has a half-life of 2–4 h which explains the relatively short duration of effects. It has a rapid peak plasma level of about 30 min via several routes, although the pharmacokinetics following dermal absorption are not well described. Review of the literature reveals only 1 other case of dermal ketamine absorption causing apnea in a child. Our case had a similar presentation. Conclusions: Compounded prescription pain creams may contain potent ingredients with the potential to cause rapid onset of apnea requiring airway intervention, even via the dermal route. Non-standard labels may lead to confusion and delayed treatment in unplanned exposures. Dispensing pharmacies should counsel patients regarding safety, and standardized abbreviations of medications would aid poison providers in triage, diagnosis and treatment.