A 24-year-old guy presented come the emergency department with altered sensorium. He to be awake, alert, and also oriented come person and also place only, with erratic, dissociative behavior, consisting of hallucinations. He had been offered naloxone in the field, which had resulted in mild improvement.
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On physical examination, the patient was in hypertensive urgency, through a blood push of 209/118 mm Hg. His mood to be euphoric and also hyperalert, through inappropriate laughing. He to be hallucinating. He to be agitated and diaphoretic. His pupils were dilated and also equally reactive, v vertical and also horizontal nystagmus. Mucous membranes were dry. His Glasgow Coma range score to be 14 the 15. No focal length neurologic deficits were appreciated. Cardiac examination revealed just sinus tachycardia, v the beats every minute in the 120s._________________________________________________________________________________________________________________________________________________________Related ContentThe Potential effect of Marijuana and Tobacco on Warfarin Metabolism and also INRMarijuana usage Can readjust Brain"s physics Structure________________________________________________________________________________________________________________________________________________________
Results of laboratory studies proved hypokalemia (2.5 mEq/L potassium), acute renal insufficiency (creatinine clearance, 1.8 mg/dL; baseline, 1.0 mg/dL), and also elevated creatine kinase (2400 U/L).
Computed tomography scan that the head revealed no acute findings. Electrocardiography revealed sinus tachycardia. Chest radiography revealed no acute pulmonary findings. Outcomes of a to pee toxicology screen were positive for phencyclidine (PCP) and marijuana.
He got a presumptive diagnosis that PCP intoxication and also was managed with intravenous fluids, benzodiazepines, electrolyte replacement, antihypertensives, and soft restraints as needed.
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Overnight, his problem improved. His electrolyte levels normalized, and his renal function returned come baseline. His mentation cleared, and also when he was interviewed the following morning, he refuse the usage of PCP however admitting to taking approximately 10 pills that a Coricidin HBP product (containing dextromethorphan) the night prior to to “get high.”
Dextromethorphan is one over-the-counter (OTC) cough suppressant that is generally used together a recreational drug amongst young adults. The is an isomer the codeine and shares a similar chemical framework to PCP (Figure).1 Its active metabolite is dextrorphan, one N-methyl-d-aspartate (NMDA) receptor antagonist, which in instances of intoxication leads to a unique combination of hallucinations, out-of-body sensations, dissociation, and inhibition the adrenergic reuptake. This consequently leads to tachycardia, hypertension, and diaphoresis.1
In enhancement to dextromethorphan, OTC sneeze formulations frequently contain other agents such as the antihistamine chlorpheniramine. Coingestion the dextromethorphan and also antihistamines leads to attributes of anticholinergic poisoning, such together tachycardia, hypertension, hyperthermia, flushing, warm and dry skin, and agitated delirium.2 Hyperthermia, agitation, seizures, and also muscle rigidity may lead to rhabdomyolysis and also renal failure.2 Serotonin syndrome deserve to complicate the presentation.2
Approximately 1 million us young adult misuse OTC cough and cold medicines containing dextromethorphan every year.3 The brands Coricidin, Nyquil, and Robitussin account for almost 66% that such situations of misuse.3 Furthermore, young adults regularly simultaneously usage marijuana through dextromethorphan-containing products.4
Testing for dextromethorphan sloop down is difficult, due to the fact that rapid urine drug display screens do not detect it; thus, the diagnosis usually is based upon the patient’s history and clinical findings.5 Moreover, dextromethorphan can cause a false positive result for PCP on fast urine drug screens,1,6 because dextromethorphan and also PCP space both NMDA receptor antagonists, are dopamine agonists, and inhibit serotonin reuptake, and also because the screening test for PCP offers an antibody with a structure comparable to dextromethorphan.1,7
Tulisa LaRocca, MD, is an affiliated assistant professor of medication at the university of Miami Miller college of Medicine, Palm Beach local Campus, in Atlantis, Florida.