UMEM Educational Pearls

Category: Toxicology

Title: "Triple C" Overdose

Keywords: Dextromethorphan, Robotripping (PubMed Search)

Posted: 4/20/2017 by Kathy Prybys, DO (Emailed: 4/27/2017)
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Takeaways

A 17 y/o male presented for altered mental status. His mother stated she was contacted by neighbor concerned that her son was wandering down the middle of a local roadway. His friends stated he had taken 16-17 "triple C's" in an attempt to "get high". No other coingestants were identified. At presentation, the patient appeared to be in an toxic delirium. VS : 187/112, 116, 16, 98.9, 100% RA. Patient  was awake with eyes open but slowly responsive.GCS was 12. No evidence for trauma. Pupils were dilated and slowly reactive. The rest of the exam was essentially negative.
 
  • Coricidin Cough & Cold medicine also known by street name 'Triple C" is the most commonly reported abused dextromethorphan-containing product.
  • Dextromethorphan at high doses acts as a dissociative general anesthetic and hallucinogen similar to Ketamine and Phencyclidine (PCP) by antagonizing the NMDA receptor in a dose dependent manner.
  • Detromethorphan-containing products are appealing to teens as they are easily available (OTC), legal, inexpensive, and preceived as safe. 
  • Street names for dextromethorphan products include DXM, CCC, Trile C, Skittles, Robo, Poor Man's PCP,. Abuse of Robitussin products is referred to as "Robotripping"
  • Additional toxicity can occur from the coingredients (pseudoephedrine, acetaminophen, and antihistamines such as Chlorpheniramine) is a serious concern of taking large amounts of OTC cough and cold medications for the Dextromethorphan content. Chlorpheneriamine is a  first generation H1-histamine receptor antagonist with potent antimuscarinic properties.
  • Dextromethorphan is not detected by basic drug screens and should be considered when evaluating patients with a dissociative toxidrome. Acetaminophen levels should be obtained.
  • No specific antidote exists for dextromethorphan toxicity. Benzodiazepines should be administered for seizures and aggressive cooling measures for hyperthermia. Naloxone can be considered for use in patients in a coma or with respiratory depression but variable results are reported.
 

In-Depth

Coricidin   HBP Cough & Cold

References

Dextromethorphan Abuse in Adolescence. Bryner JK,  Wang K, et al.  Archives of Pediatrics & Adolescent Medicine. 2006;160(12):1217-1222. doi:10.1001/archpedi.160.12.1217.

Dextromethorphan abuse. Antoniou T, Juurlink DN. CMAJ?: Canadian Medical Association Journal. 2014;186(16):E631. doi:10.1503/cmaj.131676.