The objective of this guideline is to assist
poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected ingestion of
dextromethorphan by 1) describing the process by which an ingestion of
dextromethorphan might be managed, 2) identifying the key decision elements in managing cases of
dextromethorphan ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to the ingestion of
dextromethorphan alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) Patients who exhibit more than mild effects (e.g., infrequent
vomiting or
somnolence [lightly sedated and arousable with speaking voice or light touch]) after an acute
dextromethorphan ingestion should be referred to an emergency department (Grade C). 3) Patients who have ingested 5-7.5 mg/kg should receive
poison center-initiated follow-up approximately every 2 hours for up to 4 hours after ingestion. Refer to an emergency department if more than mild symptoms develop (Grade D). 4) Patients who have ingested more than 7.5 mg/kg should be referred to an emergency department for evaluation (Grade C). 5) If the patient is taking other medications likely to interact with
dextromethorphan and cause
serotonin syndrome, such as
monoamine oxidase inhibitors or
selective serotonin reuptake inhibitors,
poison center-initiated follow-up every 2 hours for 8 hours is recommended (Grade D). 6) Patients who are asymptomatic and more than 4 hours have elapsed since the time of ingestion can be observed at home (Grade C). 7) Do not induce
emesis (Grade D). 8) Do not use
activated charcoal at home.
Activated charcoal can be administered to asymptomatic patients who have ingested overdoses of
dextromethorphan within the preceding hour. Its administration, if available, should only be carried out by health professionals and only if no
contraindications are present. Do not delay transportation in order to administer
activated charcoal (Grade D). 9) For patients who have ingested
dextromethorphan and are sedated or
comatose,
naloxone, in the usual doses for treatment of
opioid overdose, can be considered for prehospital administration, particularly if the patient has
respiratory depression (Grade C). 10) Use intravenous
benzodiazepines for
seizures and
benzodiazepines and external cooling measures for
hyperthermia (>104 degrees F, >40 degrees C) for
serotonin syndrome. This should be done in consultation with and authorized by EMS medical direction, by a written treatment protocol or policy, or with direct medical oversight (Grade C). 11) Carefully ascertain by history whether other drugs, such as
acetaminophen, were involved in the incident and assess the risk for toxicity or for a drug interaction.