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

Toxicity, Cough and Cold Preparation: Treatment & Medication

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

Treatment

Medical Care

  • General guidelines for treatment of cough and cold preparation poisoning
    • Ensure the patient has adequate airway, breathing, and circulation. Place the child on a cardiorespiratory monitor and/or obtain intravenous (IV) access if the child appears ill or is symptomatic. Administer oxygen, naloxone, and glucose to the patient if an unexplained decreased level of consciousness is observed.
    • Obtain the patient's history through a relative or Emergency Medical Technician (EMT). Examine the patient, looking for an anticholinergic toxidrome.
    • Obtain appropriate lab tests and an ECG.
    • Consider decontamination with activated charcoal.
    • Provide other supportive measures. Consider admission to a hospital if ingestion is significant or if the patient continues to be symptomatic.
    • Contact the regional poison control center.
  • GI decontamination
    • Activated charcoal is the first-line defense in GI decontamination and should be given to the patient if a significant ingestion has occurred within recent hours before presentation.
    • Optimal dose of charcoal is not well established. The usual dose is 25-100 g in adults and adolescents, 25-50 g in children aged 1-12 years, and 1 g/kg in infants younger than 1 year. It is most effective if administered within 1 hour of ingestion.
    • Complications include emesis and aspiration.
  • Other methods of decontamination
    • Controversial methods of decontamination include gastric lavage and ipecac syrup. Use of these agents should be on the advice of a poison center or toxicologist.
    • Ipecac and gastric lavage have fallen into disfavor, and cathartic therapy is not recommended, especially in children. Emesis is not usually recommended and is specifically contraindicated if a depressed gag reflex, CNS depression, ingestion of a corrosive substance, or situation with high aspiration potential is noted.
  • Treatment of dystonic reactions
    • Dystonic reactions are treated with diphenhydramine in doses of 1 mg/kg IV every 2 minutes, with a maximum of 5 mg/kg/d, unless the dystonic reaction is thought to be caused by or involve antihistamine intoxication.
    • Acute dystonic reactions to antihistamines may be treated with oral (PO) or IV diazepam in children. The dose is 0.1-0.3 mg/kg (slowly if IV) and as much as 10 mg in adults.
  • Treatment of seizures
    • Seizures can be treated with lorazepam. The pediatric dose is 0.05-0.1 mg/kg every 5 minutes as needed.
    • Monitor for hypotension, respiratory depression, and the need for endotracheal intubation.
  • Treatment of serotonin syndrome
    • Serotonin syndrome must be managed by addressing each symptom individually.
    • Hyperthermia should be managed by undressing the patient and enhancing evaporative heat loss by keeping the skin damp and using cooling fans.
    • Muscle activity and agitation may be diminished with the use of diazepam.
    • Cyproheptadine is a nonspecific 5-hydroxytryptamine (5HT, serotonin) antagonist that has been shown to block development of serotonin syndrome in animals and is suggested as an antidote for serotonin syndrome in humans. It is available only as an oral preparation.
    • Propranolol also has been used to some benefit as a 5HT1A receptor antagonist.
  • Treatment of other conditions
    • Cardiac arrhythmia can be managed with the appropriate cardiac medicine per pediatric advanced life support (PALS) guidelines.7 In diphenhydramine overdoses, bicarbonate may be helpful in treating QRS complex abnormalities and cardiac dysrhythmias. Treatment with bicarbonate in this overdose should be used in concert with poison center or medical toxicology consultation.
    • Rhabdomyolysis needs to be managed by ensuring adequate hydration and renal function, followed by a solution of sodium bicarbonate and potassium chloride to produce adequate urine flow and a urine pH of at least 7.5. Monitor sodium pH to avoid inducing severe alkalemia. Furosemide or mannitol may be needed to maintain diuresis. Chart strict intake and outputs.
    • Muscle rigidity and hyperactivity are secondary to sympathomimetic toxicity and can be controlled with neuromuscular paralysis.
    • Hyperthermia associated with sympathomimetics can be controlled with external evaporative cooling, removing the patient's clothes, and spraying with tepid water and fanning.
  • Use of physostigmine
    • Use of physostigmine in antihistamine poisoning is extremely controversial, and it should not be given unless directed by a regional poison control center or in direct consultation with a medical toxicologist. Physostigmine, an anticholinesterase, may be indicated in the suspected anticholinergic poisoning for its therapeutic value.
    • It is a tertiary amine that crosses the blood brain barrier and reverses both the central and the peripheral effects of anticholinergics. Long-lasting reversal of anticholinergic signs and symptoms is not achieved because of the relatively short duration of action from physostigmine (20-60 min). Indications are severe life-threatening complications, such as coma, hypotension with dysrhythmias unresponsive to other attempts at treatment, and intractable seizures.
    • Adolescent and adult trial dosages are 2 mg IV slowly every 5 minutes. To administer, dilute the dose of physostigmine in 10 mL of dextrose 5% in water (D5W) or in 10 mL of isotonic sodium chloride solution.

Consultations

  • Contact a regional poison control center.
  • Consult a toxicologist or pediatric toxicologist.
  • Psychiatric and neurologic complications require consultation.

Medication

Antidotes

These agents are used in the management of poisoning and overdose, prevention of toxic effects, and metabolic disorders in which toxic substances accrue. Mechanisms of action vary (eg, antagonists, toxin transformation, altered metabolism, chelation, directed antibodies).


Physostigmine (Antilirium)

Use of physostigmine in antihistamine poisoning is extremely controversial, and it should not be given unless directed by a regional poison control center or in direct consultation with a toxicologist. Physostigmine, an anticholinesterase, may be indicated in the suspected anticholinergic poisoning for its therapeutic and diagnostic value.

Adult

Adolescent and adult trial dosages are 2 mg IV slowly q5min
To administer, dilute the dose of physostigmine in 10 mL of D5W or NS

Pediatric

Trial doses of 0.02 mg/kg or 0.5 mg IV given slowly q5min initially
To administer physostigmine, dilute the dose of physostigmine in 10 mL of D5W or NS
The therapeutic dose is the lowest effective trial dose of physostigmine, which should be repeated if life-threatening symptoms recur

If tricyclic antidepressants were ingested, the use of physostigmine is contraindicated and may precipitate intractable seizures and cardiac arrest; prolonged respiratory depression may occur with bethanechol, methacholine, or succinylcholine

Documented hypersensitivity; cardiovascular disease; heart block; bronchospasm; vagotonic symptoms (especially bradycardia); intestinal and/or bladder obstruction; severe peripheral vascular disease (gangrene); diabetes; recent administration of succinylcholine; tricyclic antidepressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Physostigmine, even when used appropriately, may precipitate seizures, cholinergic crisis, arrhythmias, or cardiac arrest; potential adverse effects include asystole in the setting of conduction disturbance or cyclic antidepressant toxicity, seizures, muscle weakness, cholinergic crisis (eg, bradycardia, salivation, lacrimation, bronchospasm, bronchorrhea, diarrhea); before use, confirm presence of normal ECG (no conduction disturbance), absence of exposure to other cardiotoxic substances, and presence of peripheral and central signs of antimuscarinic toxicity; as added precaution, have atropine at bedside for use if cholinergic symptoms develop


Diphenhydramine (Benadryl)

DOC for initial treatment of acute dystonia or akathisia not caused by antihistamines. Use diazepam for treatment of acute dystonia secondary to antihistamines.

Adult

25-50 mg PO q6-8h prn; not to exceed 400 mg/d
10-50 mg IV/IM q6-8hprn; not to exceed 400 mg/d

Pediatric

1 mg/kg IV q2min, not to exceed 5 mg/kg/d or 300 mg/d

Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions

Documented hypersensitivity; MAOIs

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, or urinary tract obstruction; xerostomia may occur


Diazepam (Valium)

For treatment of acute dystonic reactions caused by antihistamines. Also indicated for muscle activity and agitation associated with serotonin syndrome. Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.

Adult

5-15 mg IV q5min, repeat prn; not to exceed 30 mg in 8 h

Pediatric

0.1-0.3 mg/kg/dose PO or IV (infused over 2-3 min) q15-30min; repeat in 2-4 h prn; not to exceed 10 mg for cumulative dose

Phenothiazines, barbiturates, alcohols, and MAOIs increase CNS toxicity when administered concurrently

Documented hypersensitivity; narrow-angle glaucoma

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)


Lorazepam (Ativan)

Used to treat seizures. Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Important to monitor patient's blood pressure after administering dose. Adjust prn.

Adult

4 mg/dose IV slowly over 2-5 min and repeat in 10-15 min prn; not to exceed 8/mg dose
1-10 mg/d PO/IV/IM divided bid/tid

Pediatric

Infants and children: 0.1 mg/kg IV slowly over 2-5 min; repeat prn in 10-15 min at 0.05 mg/kg; not to exceed 4 mg/dose
Adolescents: 0.07 mg/kg IV slowly over 2-5 min and repeat in 10-15 min prn; not to exceed 4 mg/dose

Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs

Documented hypersensitivity; preexisting CNS depression, hypotension, and narrow-angle glaucoma

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease; monitor for hypotension and respiratory depression


Naloxone (Narcan)

Used to treat opioid overdose. Prevents or reverses opioid effects (hypotension, respiratory depression, sedation), possibly by displacing opiates from their receptors. Possesses short onset of action (2 min), duration of action is 30-60 min, and half-life is 1 h. May also be administered via endotracheal tube at 2-2.5 times the IV dose.

Adult

0.4-2 mg IV/IM; may be repeated in 1-2 min intervals following IV use and 10 min intervals following IM use; not to exceed cumulative dose of 10 mg

Pediatric

0.01 mg/kg/dose IV/IM
<20 kg or <5 years: 0.1 mg/kg/dose IV/IM not to exceed 2 mg/dose
>20 kg or >5 years: 0.1-2 mg/dose IV/IM; may repeat dose prn; not to exceed cumulative dose of 10 mg

Compatible with bisulfite and alkaline IV solutions; decreases the analgesic effects of narcotics

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in cardiovascular disease (may cause tachycardia, hypertension, or dysrhythmias); also know to cause nausea, vomiting, diaphoresis, blurred vision, or seizures; may precipitate withdrawal symptoms in patients addicted to opiates

Decontamination agents

Consider activated charcoal decontamination in any patient who presents within 4 hours of ingestion.


Activated charcoal (Actidose-Aqua, Liqui-Char)

Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.

Adult

25-100 g PO as a single dose

Pediatric

<1 year: 1 g/kg PO as a single dose
1-12 years: 25-50 g PO as a single dose
Adolescents: Administer as in adults

May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases adsorptive properties)

Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adverse effects include nausea, vomiting, and possible aspiration in an unprotected airway; stools turn back from the charcoal; monitor for bowel sounds

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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