II. Background

  1. Dextromethorphan Abuse is increasing in United States (especially among teens)
  2. Coricidin ("skittles", Triple C) is a common source of Dextromethorphan for abuse
  3. Some users try to extract Dextromethorphan from OTC preparations (Crystal-Dex)

III. Mechanism

  1. Dextromethorphan has NMDA activity and serotonergic activity

IV. Signs

  1. General
    1. Altered Level of Consciousness
    2. Does not typically cause respiratory depression
  2. Dose-Dependent Effects
    1. Low dose
      1. Ataxia on ambulation ("robo walk")
    2. High dose (>200 mg Dextromethorphan)
      1. Euphoria
      2. Auditory Hallucinations and Visual Hallucinations
    3. Very high dose
      1. Complete dissociation
  3. Combination product abuse
    1. Acetaminophen Toxicity risk (see below)
    2. Products containing Diphenhydramine might present with Anticholinergic Toxicity

V. Labs

  1. Hyperchloremia and normal Anion Gap
    1. Limited to Dextromethorphan preparations containing hydrobromide salt
  2. Acetaminophen Level
    1. Elevated if combination product was abused

VI. Precautions

  1. Acetaminophen Toxicity risk
    1. Many Dextromethorphan products also contain Acetaminophen
  2. Anticholinergic Toxicity risk
    1. Associated with combination agent Overdose containing Diphenhydramine
    2. "Cheese" (Heroin with Dextromethorphan and Diphenhydramine)

VII. Management

  1. Supportive care
  2. Naloxone is unlikely to have much effect unless there is respiratory depression

VIII. Course

  1. Short acting agents: 6 hours
  2. Long acting agents (Delsym): 12 hours

IX. Complications

  1. Serotonin Syndrome (when combined with other serotonergic agents)

X. References

  1. Fontes (2014) Crit Dec Emerg Med 28(1): 14-24
  2. Nordt and Swadron in Majoewsky (2012) EM: RAP 12(5): 3

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