Case of the Month
February 2006

14-year-old female — Possible cough syrup overdose

Dispatch

"Aid 82, Medic 19; 14-year-old female, decreased level of consciousness"

En route your crew discusses the following considerations:

• reasons for decreased level of consciousness
• glucometry
• scene safety

Dispatch relays that the patient was found semiconscious by her parents and has vomited once; there is possibly a second patient.

Scene Size-up
You arrive and find an extremely upset woman who meets you at the street in front of the residence. She leads you through the house and down into the basement where you find two adolescent girls, one almost unconscious (Patient #1) and a second (Patient #2) sitting up and staring straight ahead. You immediately request a second BLS crew. Aid 83 is dispatched.

Initial Assessment
You assign one of your three-person team to the patient who is sitting up and staring; meanwhile you and your other partner work up the female who appears unconscious.

Your partner completes an initial assessment for Patient #1:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Short report to the medics?

Initial Treatment
You decide that Patient #1 is SICK based on a decreased level of consciousness, pale, moist skin and not knowing the cause. Patient #2 is SICK based on a decreased level of consciousness and high index of suspicion.

You quickly advise the medic unit that you have "two patients, both SICK, both with decreased LOC, evaluating further" and begin oxygen therapy using a NRM at 10 liters per minute. You also place your patient in the recovery position, in case she vomits again.

Physical Exam
Your partner gives you the following information:

HEENT	—	Skin is cool, moist, and pale. Pupils are equal, very dilated, and react slowly to light.
Chest	—	Breath sounds are clear on both sides but with shallow exchange.
Abdomen	—	Unremarkable.
Extremities	—	Some movement, otherwise unremarkable.
Neuro	—	Opens eyes and talks incoherently with slurred speech when noxious stimulus is applied.

SAMPLE

Second Set of Vital Signs

Your partner checks Patient #1's blood glucose level and finds it to be 97 mg/dl.

Because the girls are not able to speak, you look around the room for clues as to what happened. Quickly you find three 12 oz bottles of 'Robitussin DM' and 8 empty blister packets (8 tablets total) that had contained 'Coricidin' cough and cold medicine. You also find four empty beer bottles.

The medic unit arrives and one medic starts an IV on patient #1. Since she is not able to protect her airway, they decide to intubate. The second patient is quickly evaluated and it is decided to start an IV on her also. The first medic transports Patient #1 in the medic unit with an EMT driving and a second bagging the patient. The second medic rides with Aid 82 for transport of Patient #2.

Lessons Learned from this Case
Dextromethorphan (DXM) is the most common anti-cough ingredient in over the counter cough remedies – both syrups and tablets. It is also legally available in a pure powdered form. It is chemically similar to the opiate family of drugs, but it is significantly different enough to not carry the same hazards at a lower dose. When taken in high doses the drug initially causes sleepiness and then a hallucinatory effect. Also, the syrup can cause nausea and vomiting in large quantities. Overdose can lead to respiratory depression, respiratory arrest, seizures and death.

Since cough remedies often contain other significant medications, a patient who has ingested high doses of a DXM-containing preparation may also suffer the consequences of the other drugs that are present. Some of the other drugs commonly mixed into cold and cough remedies include chlorpheniramine, acetaminophen, guaifenesin and pseudoephedrine among others.

Typical signs and symptoms of a DXM overdose include decreased LOC, slurred speech, poor gait, inability to focus eyes, nystagmus, nausea and vomiting, low blood pressure, slow heart rate and slow shallow breathing. Medical literature has reported some cases where pinpoint pupils were present. It is unknown whether naloxone (Narcan) is an effective treatment or not.

On the street, getting high on DXM can be known as "Robo-tripping," "dropping Robo" or "Skittling." Skittling refers to taking tablets that contain DXM as the tablets often appear somewhat like the candy Skittles. Other slang terms are "Candy," "Rojo," "Velvet" and "DM."  "C," "CCC" or "Triple C" refer specifically to Coricidin brand cough and cold medication. The literature suggests this particular product is more dangerous than others.