View source for Dextromethorphan toxicity

==Background==
*Antitussive agent
*Acts on opioid and seratonin receptors
*At high doses has phencyclidine (PCP) and ketamine like effects on the NMDA receptor system
*High abuse in 12-25 year olds for euphoric and dissociative properties
** "Skittles", "Robotripping"
[[File:330px-DXM Doses.jpg|thumbnail|Bright red pills resemble skittles]]

==Clinical Features==
*Diaphoresis
*Visual field distortion and dilated pupils
*Excitement, euphoria, hallucinations, loss of time, feelings of dissociation, inappropriate laughing
*Less respiratory depression compared to other opioids (doesn't act on mu/delta receptors)
*Reactions with other medications
**If anti-H1 in combination, [[Anticholinergic toxicity]]
**If α-agonist in combination, hypertension and reflex bradycardia
**If [[Acetaminophen (Tylenol) Toxicity|Acetaminophen]] in combination, hepatic toxicity
**One of several medications that may precipitate [[Serotonin Syndrome]]


Toxicity is dose dependant<ref>Logan BK, Yeakel JK, Goldfogel G, et al. Dextromethorphan abuse leading to assault, suicide, or homicide. J Forensic Sci 2012; 57:1388.</ref>
*Normal dose of nyquil (30 mL) has 30 mg of dextromethorphan
{| class="wikitable"
|-
! Plateau !! Dose !! Symptoms
|-
| 1 || 100 to 200 mg || Mild stimulation, change in gravity perception
|-
| 2 || 200 to 400 mg || Euphoria and hallucinations
|-
| 3 || 300 to 600 mg || Dissociative and out of body sensation
|-
| 4 || >600 mg || Complete dissociation and unresponsiveness, coma
|}

==Differential Diagnosis==
*Dissociative drugs
**Dextrorphan
**[[Ketamine]]
**[[Nitrous oxide]]
**Phencyclidine (PCP)
*Hallucinogen
*NMDA receptor antagonist

==Diagnosis==
*Given AMS, key importance of witnesses and EMS recovery of medication bottles
*Acetaminophen level (combination cold medicine)
*Urine drug screen may be positive for PCP or opiates

==Management==
*Supportive care
**IV hydration
**Cooling
**Benzodiazepines
*Naloxone is unlikely to have much effect unless there is respiratory depression

==Disposition==

==See Also==
*[[Serotonin Syndrome]]
*[[Anticholinergic Toxicity]]

==References==
<references/>

[[Category:Tox]]