UMEM Educational Pearls

Title: "Triple C" Overdose

Keywords: Dextromethorphan, Robotripping (PubMed Search)

Posted: 4/20/2017 by Kathy Prybys, MD
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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.

Additional Information

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.