Cough and Cold Preparation Toxicity Clinical Presentation

  • Author: Laleh Gharahbaghian, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Aug 1, 2011
 

History

  • Unintentional ingestion of cough and cold preparation
    • Unintentional exposures tend to occur in children younger than 6 years because they are eager to explore their environment and place objects into their mouths.
    • Unintentional ingestion typically represents a smaller dose of the toxic substance, and the child presents to the emergency department soon after ingestion.
    • Unfortunately, as many as 30% of children who experience one ingestion experience a repeat ingestion. In this age group, the possibility of child abuse or neglect should be explored.
  • Intentional ingestion
    • Only 47% of reported adolescent ingestions are accidental, others are motivated by suicidal intention or recreational abuse. Both suicidal and recreational ingestion occur with increased frequency in the teenage population, and it may involve multiple substances at higher doses.
    • Dextromethorphan has been used as a recreational drug by adolescents. A 2006 study showed a 10-fold increase in California Poison Control System dextromethorphan abuse cases from 1999 (0.23 cases per 1000 calls) to 2004 (2.15 cases per 1000 calls).[6] Coricidin HBP Cough & Cold Tablets were the most commonly reported dextromethorphan-containing products abused, followed by dextromethorphan-containing Robitussin formulations.
    • Eliciting the specific OTC medication ingested is important because dextromethorphan is often present in combination with pseudoephedrine, antihistamines/anticholinergics, and acetaminophen.
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Physical

  • General findings
    • Physical findings widely vary, depending on the agent or combination of agents ingested.
    • If a single antihistamine agent has been ingested, a predominance of anticholinergic effects are demonstrated. The anticholinergic toxidrome consists of agitation; fever; urinary retention; dry, hot, flushed skin; and dilated pupils.
    • Although most cough and cold preparations are a combination of medications, a single toxidrome may not be present. The history is helpful to guide the expected physical examination findings; however, the history is often inaccurate.
  • The following physical examination findings are examples of what is possible, in addition to the common findings; however, the presentation of a patient with a toxic ingestion is not always straightforward. In general, the combined effects of the various classes of drugs in OTC preparations have been broken down into the following systems based on the approach in POISINDEX.
    • Vital signs
      • Findings include hyperthermia, tachypnea, tachycardia, and hypertension.
      • Hyperthermia has been reported with ingestion of both diphenhydramine and OTC antihistamine/decongestant combinations. Case reports secondary to combination products are ascribed to the sympathomimetic component.
    • Head, ears, eyes, nose, and throat (HEENT)
      • Anticholinergic effects include mydriasis, nasal dryness and stuffiness, eye dryness, and mouth and throat dryness secondary to antihistamines.
      • Dilated and minimally reactive pupils have been seen with antihistamine toxicity related to anticholinergic effects.
      • Mydriasis and nystagmus may be observed with dextromethorphan ingestion.
  • Cardiovascular
    • Abnormalities include arrhythmia (eg, atrioventricular [AV] block) and cardiac arrest.
    • ECG changes occur secondary to the antihistamine and the sympathomimetic components. Antihistamines commonly cause tachycardia.
  • Respiratory: Findings include respiratory depression and adult respiratory distress syndrome.
  • Neurologic: Abnormal findings include dizziness, ataxia, hyperexcitability, somnolence, seizures, dystonia, dyskinesia, toxic psychosis (anxiety, agitation, hallucination), intracranial hemorrhage, and coma.
  • GI: Gastroenteritis (diarrhea, nausea, vomiting) can occur with the ethanolamine class of antihistamines.
  • Genitourinary
    • Urinary retention is a common anticholinergic adverse effect of the antihistamines.
    • Rhabdomyolysis (ie, decreased urinary output and increased creatinine phosphokinase) has been associated with doxylamine overdose and may require treatment with intravenous (IV) hydration, furosemide, and urine alkalization.
  • Hematologic
    • Most hematologic effects are secondary to long-term use.
    • Findings include hemolytic anemia, thrombocytopenia, and agranulocytosis
  • Psychiatric: Children may experience visual hallucinations following therapeutic doses of triprolidine (antihistamine/pseudoephedrine) combinations.
  • Dermatologic: Urticaria and hot, dry skin may be noted.
  • Effects during breastfeeding: Potential changes in behavior of the infant include irritability, disturbed sleep patterns, and excessive crying.
  • Other: Drug interactions between monoamine oxidase inhibitors (MAOIs) or serotonin reuptake inhibitors with dextromethorphan may result in a serotonin syndrome. Serotonin syndrome consists of mental status changes, such as agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, headache, fever, or incoordination.
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Causes

  • Drug abuse has been reported with dextromethorphan. Easy accessibility and a false sense of safety have contributed to its increase in recreational use.
  • Deliberate ingestion can lead to intoxication with symptoms of euphoria, bizarre behavior, hyperactivity, auditory hallucinations, visual hallucinations, and association of sounds with colors.
  • Slang names for dextromethorphan include CCC, triple C, DXM, dex, poor man's PCP, skittles, and robo.
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Contributor Information and Disclosures
Author

Laleh Gharahbaghian, MD  Co-Director, Emergency Ultrasound Fellowship, Associate Director, Emergency Ultrasound, Clinical Instructor, Division of Emergency Medicine, Stanford University Medical Center

Laleh Gharahbaghian, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Lopez, MD  Attending Physician, Department of Emergency Medicine, Queen of the Valley Medical Center, Sutter Solano Medical Center

Nicholas Lopez, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Jennifer A Oman, MD  Associate Clinical Professor, Department of Emergency Medicine, University of California, Irvine, School of Medicine

Jennifer A Oman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

William T Zempsky, MD  Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Paul D Petry, DO, FACOP, FAAP  Consulting Staff, Freeman Pediatric Care, Freeman Health System

Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

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