In North America, opioid-related deaths are on the rise. We report a case of pediatric cardiac toxicity likely related to illicit fentanyl ingestion. A 14-year-old male ingested half of an illicit pill. Two hours post-ingestion, the patient experienced loss of consciousness, hypotension, cyanosis and diaphoresis. He reported chest pain 8 hours post-hospital arrival. Initial lab reports revealed elevations in lactate and high-sensitivity troponin concentrations. A chest radiograph revealed a right-sided aspiration pneumonia. An electrocardiogram showed ST elevation over the anterior leads and T wave inversion over the inferior leads. An echocardiogram demonstrated borderline systolic function. Initial cardiac magnetic resonance imaging revealed inflammation. Comprehensive urine drug screen was positive for fentanyl and its metabolites, cannabinoids, ondansetron, metoclopramide and ranitidine and was negative for xylazine. The management included administration of non-invasive positive-pressure ventilation, naloxone, acetaminophen, ceftriaxone, and clindamycin. Hypotension was treated with calcium gluconate, dopamine, and norepinephrine. He was able to wean off inotropes the next day and went home 5 days postpresentation. A repeat cardiac MRI performed six months post-ingestion was normal. Illicit fentanyl use in an adolescent appeared to cause myocardial injury with cardiogenic shock, elevated serum troponins, and transient abnormalities on electrocardiography and cardiac imaging.