eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Cough and Cold Preparation: Differential Diagnoses & Workup

Author: Laleh Gharahbaghian, MD, Co-Director, Emergency Ultrasound Fellowship, Associate Director, Emergency Ultrasound, Clinical Instructor, Emergency Medicine, Stanford University Medical Center
Coauthor(s): Nicholas Lopez, MD, Resident Physician, Department of Emergency Medicine, Stanford University Medical Center, Kaiser Permanente Santa Clara Medical Center; Jennifer Oman, MD, Associate Clinical Professor, Department of Emergency Medicine, University of California at Irvine
Contributor Information and Disclosures

Updated: Sep 24, 2009

Differential Diagnoses

Child Abuse & Neglect: Physical Abuse
Meningitis, Aseptic
Conduct Disorder
Meningitis, Bacterial
Diabetic Ketoacidosis
Munchausen Syndrome by Proxy
Fever in the Toddler
Respiratory Distress Syndrome
Fever in the Young Infant
Substance Abuse: Cocaine
Fever Without a Focus
Toxicity, Ethanol
Head Trauma
Hypoglycemia

Other Problems to Be Considered

  • Altered mental status - Trauma, tumor, intussusception, shock, alcohol or drug abuse, epilepsy, encephalopathy, inborn errors, opiates, uremia
  • Neurologic conditions - Subdural or arachnoid hemorrhage
  • Psychosis - Psychiatric (schizophrenia, mania), drug-induced (amphetamines, hallucinogens), withdrawal states (alcohol, barbiturates), cerebrovascular, endocrine (hyperthyroid, steroid), hypoxia (carbon monoxide, anemia), metabolic (encephalopathy, uremia), neoplastic (glioblastoma), pyogenic infections (CNS abscess, sepsis), seizure disorder (postictal psychosis, temporal lobe seizures), trauma, viral infections (encephalitis)
  • Seizures - Febrile, new-onset, drug-induced

Workup

Laboratory Studies

The following studies are indicated in suspected cough and cold preparation toxicity:

  • Emergency drug screens
    • Emergency drug screens rarely aid clinical decisions because turn-around time often is very long; furthermore, screens are not sensitive or specific for many drugs, leading to either a missed diagnosis or a false diagnosis of systemic drug presence.
    • In addition, a positive screen result is difficult to use as the explanation for a patient's presentation because cause and effect can be ascertained only from patient history.
    • In the setting of an intentional overdose, the patient's history may be unreliable and unverifiable.
    • In general, drug screens are ordered when poisoning is suspected as the cause of an altered level of consciousness, unexplained seizures, or new onset of unusual behavior.
    • Drugs can be screened in blood or urine. Serum concentrations of over-the-counter (OTC) cough and cold preparations are not helpful.
    • Which drug screens to order should be decided in coordination with a regional toxicology center because most of these tests are costly and add little to a complete history with a known ingestion.
  • Blood and urine analysis
    • An electrolyte panel and a CBC count are recommended for all cases of possible toxicity.
    • A plasma creatinine kinase level test may be helpful if rhabdomyolysis is suspected secondary to a antihistamine/decongestant combination that contains phenylpropanolamine, pseudoephedrine, or phenylephrine. The test result for myoglobin should be positive if rhabdomyolysis is present.
    • Several antihistamine/decongestant combinations are also combined with salicylates or acetaminophen. Blood levels should be measured for potential concurrent acetaminophen or salicylate ingestion.

Imaging Studies

  • Imaging studies are not useful in identifying ingestion of cold and cough preparations.
  • Chest radiography is useful if the patient has severe respiratory or CNS depression. This rules out pulmonary edema and adult respiratory distress syndrome.

Other Tests

  • Electrocardiogram
    • An ECG is indicated especially if tachycardia or bradycardia is present.
    • Antihistamines may cause a prolonged QTc or QRS complex and ST-T segment abnormalities. Several cases of prolonged QTc and QRS intervals, with nonspecific ST and T wave changes, have been reported secondary to antihistamine ingestions.

Procedures

  • A lumbar puncture is helpful in excluding other causes (eg, infectious, autoimmune) of altered mental status or new-onset seizures in the setting of an unknown toxic exposure.

More on Toxicity, Cough and Cold Preparation

Overview: Toxicity, Cough and Cold Preparation
Differential Diagnoses & Workup: Toxicity, Cough and Cold Preparation
Treatment & Medication: Toxicity, Cough and Cold Preparation
Follow-up: Toxicity, Cough and Cold Preparation
Multimedia: Toxicity, Cough and Cold Preparation
References
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References

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Further Reading

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Keywords

cough and cold preparation toxicity, antihistamine toxicity, antitussive toxicity, decongestant toxicity, cough medicine ingestion, cold medicine ingestion, cough and cold medicine poisoning, incidental ingestion, unintentional ingestion, cough & cold medicine, stroke, PCP, dissociative hallucinations, dextromethorphan codeine, respiratory depression, pharmaceutical-associated fatalities, Robitussin, respiratory depression, adult respiratory distress syndrome, gastroenteritis, urinary retention, rhabdomyolysis, treatment, diagnosis

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Contributor Information and Disclosures

Author

Laleh Gharahbaghian, MD, Co-Director, Emergency Ultrasound Fellowship, Associate Director, Emergency Ultrasound, Clinical Instructor, 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, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Sonosite Honoraria Speaking and teaching

Coauthor(s)

Nicholas Lopez, MD, Resident Physician, Department of Emergency Medicine, Stanford University Medical Center, Kaiser Permanente Santa Clara 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 Oman, MD, Associate Clinical Professor, Department of Emergency Medicine, University of California at Irvine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

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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