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Cough, Cold, and Allergy Preparation Toxicity Workup

  • Author: Laleh Gharahbaghian, MD; Chief Editor: Timothy E Corden, MD  more...
Updated: Dec 29, 2015

Approach Considerations

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. Screening may be important when clinical history is lacking and the diagnosis is in question. 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.

Drugs can be screened in blood or urine. Serum concentrations of over-the-counter (OTC) cough and cold preparations are not helpful, however. Most laboratories are not capable of testing for antihistamines, and pharmacokinetic studies have not been performed to establish therapeutic or toxic blood levels. However, a review of deaths from diphenhydramine monointoxication showed average lethal levels of diphenhydramine to be 19.5 mg/L in adults, 7.4 mg/L in children, and 1.53 mg/L in infants.[66]

Several antihistamine/decongestant combinations are also combined with salicylates or acetaminophen. In patients exposed to these combinations, blood levels should be measured for potential concurrent acetaminophen or salicylate toxicity.

An electrolyte panel and a complete blood count are recommended for all cases of possible toxicity. Uncommonly, agranulocytosis has been reported with chlorpheniramine and brompheniramine. A plasma creatine kinase level test may be helpful if rhabdomyolysis is suspected secondary to antihistamine/decongestant combination that contains pseudoephedrine or phenylephrine. The test result for myoglobin should be positive if rhabdomyolysis is present.

Obtain blood cultures to rule out sepsis if the patient is hyperthermic, seriously ill, or the diagnosis of anticholinergic poisoning is questionable.

Consider liver function tests in selected patients. Cholestatic jaundice was reported after prolonged treatment with cyproheptadine. Patients with moderate hepatic impairment experienced a greater increase in desloratadine exposure than those with normal LFTs even at the same dose.[71]

Imaging studies have limited indications. Chest radiography is useful if the patient has severe respiratory or CNS depression, in order to confirm or exclude pulmonary edema and adult respiratory distress syndrome. Computerized tomography (CT) scan of the head can be considered in any patient presenting with seizures or altered mental status. CT scan may not be necessary in patients with progressive improvement, supportive history, and a nonfocal neurologic examination.

An electrocardiogram (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.

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.

Contributor Information and Disclosures

Laleh Gharahbaghian, MD Director, Emergency Ultrasound Program and Fellowship, Clinical Associate Professor, Department of Surgery, 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


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, Emergency Medicine Residents' 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, Wisconsin Medical Society

Disclosure: Nothing to disclose.


Michael J Burns, MD Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Loren Keith French, MD Attending Physician of Toxicology, Department of Emergency Medicine, Oregon Health and Sciences University and Oregon Poison Center

Disclosure: Nothing to disclose.

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Annette M Lopez, MD Toxicology Fellow, Oregon Health and Science University School of Medicine

Disclosure: Nothing to disclose.

David J McCann, MD Resident Physician, Department of Emergency Medicine, Harvard University Affiliated Emergency Medicine Residency Program, Harvard Medical School

Disclosure: Nothing to disclose.

Nathanael J McKeown, DO Assistant Professor, Department of Emergency Medicine, Oregon Health and Science University School of Medicine; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center

Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society

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.

Brett Roth, MD  Assistant Professor, Department of Emergency Medicine, Division of Clinical Toxicology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Disclosure: Nothing to disclose.

Anne Rutkowski, MD Resident Physician, Department of Emergency Medicine, Harbor-University of California at Los Angeles Medical Center

Disclosure: Nothing to disclose.

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

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.

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Terfenadine is the antihistamine most commonly associated with torsade de pointes in both acute overdose and therapeutic administration.
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