We also have step by step guides on what to do to help yourself, a friend or a family member. Miss America Camille Schrier wants to help educate others about the importance of using medications safely. Prescription opioids are effective drugs if used safely. If misused, a person can become addicted to them. It's important to be smart about your health.
Take care of your lungs: Avoid smoking or vaping any substance. Ask a doctor or pharmacist before using other cough or cold medicines that may contain dextromethorphan. Avoid sunlight, and wear protective clothing and use sunscreen SPF 30 or higher when you are outdoors. Use Promethazine DM Dextromethorphan And Promethazine exactly as directed on the label, or as prescribed by your doctor.
Do not use in larger or smaller amounts or for longer than recommended. Follow all directions on your prescription label and read all medication guides or instruction sheets.
Use the medicine exactly as directed. Do not use this medicine in a child younger than 2 years old, and carefully follow all dosing directions about use in a child 2 years or older. Promethazine can slow the breathing, which has caused death in very young children. Measure liquid medicine with the supplied syringe or a dose-measuring device not a kitchen spoon.
This medicine can affect the results of certain medical tests, and may cause false results on a pregnancy test. Tell the doctor or laboratory staff if you have taken dextromethorphan and promethazine in the past few days. Store at room temperature away from moisture and heat. Keep the bottle tightly closed when not in use. Dextromethorphan and promethazine is used when needed.
If you are on a dosing schedule, skip any missed dose. Do not use two doses at one time. Overdose symptoms may include overactive reflexes, feeling restless or confused, slow breathing, dilated pupils, or fainting.
Methods: A case series of promethazine poisonings was identified from a prospective database of poisoning admissions to a regional toxicology service. Data were extracted including demographics, details of ingestion, clinical features including delirium, complications and medical outcomes.
In addition to descriptive statistics, a fully Bayesian approach using logistic regression was undertaken to investigate the relationship between predictor variables and delirium.
Results: There were patients with presentations, including 57 patients with 78 promethazine alone overdoses. The median dose ingested was mg IQR: — mg. Median length of stay was 19 h IQR: 13—27 h , ten were admitted to the intensive care unit ICU and four were ventilated. There were no seizures, dysrhythmias or deaths. Multivariate analysis of presentations in patients where dose of promethazine ingested was known demonstrated that dose, administration of charcoal within 2 h and co-ingestants predicted whether patients developed delirium.
No relationship was shown for sex and age. A plot of probability that a patient will develop delirium vs. Conclusion: The main feature of promethazine toxicity is delirium, the probability of which can be predicted from the dose ingested.
The administration of charcoal and the presence of co-ingestants appears to reduce the probability of delirium in a predictable manner. It is primarily a histamine H 1 receptor antagonist but is also a direct antagonist at muscarinic M 1 and dopamine D 2 receptors.
Promethazine alone in either formulation is rapidly absorbed after oral administration with peak concentrations after 2—3 h. Clinical effects are seen within 20 min and its effects last 4—6 h. Reports of overdose with promethazine are predominately case reports 5—8 with only one small case series focussing on increased frequency of poisoning when promethazine was released as an OTC medication in New Zealand.
There are also reports of adverse effects from therapeutic use of promethazine including dystonic reactions, psychosis in the absence of other anticholinergic symptoms or signs and neuroleptic malignant syndrome NMS. We report a case series of consecutive promethazine overdoses over a year period to investigate the spectrum of clinical effects of promethazine taken in overdose and also to explore the relationship between possible predictor variables and the occurrence of delirium, which we believe based on previous clinical experience to be the most important clinical feature.
A case series of consecutive promethazine poisoning cases was included from presentations to a large regional toxicology treatment unit which is the primary referral centre for about people. All patients presenting with poisoning to this unit are either seen and managed in the Emergency Department ED by the toxicology service or seen, managed and admitted as an in-patient by the toxicology service. Detailed data on all presentations ED attendances and in-patient admissions are entered into a clinical database shortly after hospital discharge.
Its use for retrospective reviews has previously been assessed by the Institutional Ethics Committee as an audit and has been exempted. A preformatted admission sheet for all poisoning admissions is used by medical staff to collect data 17 and this and additional information from the medical record is entered into the database by two trained personnel blinded to any study hypotheses. In addition all admissions are reviewed on a weekly basis to finalise all data collection and resolve any discrepancies.
Since additional methods to improve the accuracy and minimize inconsistencies in medical chart reviews as subsequently outlined by Gilbert et al. All overdoses from the database between January and May were reviewed and admissions that included promethazine at any dose either as sole ingestant or with co-ingestants were extracted.
All patients had a self-reported history of promethazine ingestion confirmed on at least two occasions by ED staff and the toxicology team in addition to information available from ambulance officers, family, friends and empty drug containers. Laboratory confirmation of ingestion was not routinely utilised in promethazine ingestions.
The following information was extracted from the database: patient demographic characteristics age and sex , details of the promethazine ingestion [estimated date and time of ingestion and estimated amount ingested mg ], co-ingested drugs including specific classes of drugs where there were enough for analysis , clinical effects pulse rate and blood pressure on admission and their respective relevant maximum or minimum recording during admission, Glasgow Coma Scale GCS score on admission, minimum GCS score during admission, the presence of delirium as defined by the attending Clinical Toxicologist as a rapid onset of a disturbance in consciousness accompanied by a change in cognition , outcomes or complications [seizures, dystonic reactions, neuroleptic malignant syndrome, dysrhythmias, length of stay LOS , Intensive Care Unit ICU admission, mortality], and treatment decontamination with activated charcoal, respiratory and cardiovascular support.
Minor discrepancies in reported ingested dose that arose on repeated history taking were averaged prior to entry into the database, otherwise more major discrepancies in dose were not recorded. The administration of charcoal was a clinical decision made by the attending physician at the time.
A standard dose was 50 g. Cathartic use with sorbitol was routine up to In patients who presented on more than one occasion, the following rules were applied.
For those who only had multiple presentations of promethazine alone or only promethazine and co-ingestants, the first admission was used for sex and age calculation. All presentations were included to calculate other summary statistics. For those who had presentations of both ingestions of promethazine alone as well as with co-ingestants, the first promethazine alone presentation was used for sex and age calculations and subsequent promethazine alone presentations for other summary statistics.
The presentations with promethazine and co-ingestants were included for other summary statistics only. The toxicology service has a standardized discharge policy requiring review by the medical toxicology team and the psychiatry team. For descriptive statistics, medians and interquartile ranges IQR are reported for promethazine alone as a sole ingestant and with co-ingestants.
To explore the relationship between clinically important predictor variables and delirium, a logistic regression model was developed with the all the presentations where dose was known. Dose was considered as a covariate untransformed, as the logarithmic or in an E max model or polynomial expression. The outcome variable was the occurrence of delirium. This is a Bayesian statistical modelling program that estimates the posterior probability distribution for the parameters of interest using Markov Chain Monte Carlo MCMC numerical simulation methods and can output a variety of statistics including the mean, median and credible interval from each posterior distribution.
Decisions about the inclusion of covariates can be made by examining the probability distribution of the coefficients, e. In addition, the dispersion of the distribution provides information on the strength of the data. Because this approach does not involve hypothesis testing, there are no type I error considerations with respect to each regression coefficient.
The prior probability distributions for the regression coefficients were defined by a multivariate normal distribution with mean zero and variance of 10 relatively wide or uninformative. Model selection was based on deviance information criterion 19 and the posterior probability that the covariate had a clinically significant effect on the probability of delirium.
Selection of variables was based on visual inspection of the data and univariate analysis for the dichotomous covariates. First order interaction terms were considered in the modelling process. Goodness of fit of the model was investigated by visual inspection of plots of the predicted probabilities from the logistic regression model vs. Simulations from the final model in WinBUGS were used to create plots of the probability of delirium vs.
There were patients of whom there were presentations identified involving promethazine ingestion either alone or with co-ingestants. Fifty-seven of these patients took promethazine alone on 78 different presentations.
Table 1 outlines the clinical features, outcomes and treatment of the promethazine alone group in comparison to the whole group including co-ingestants. The dose of promethazine ingested was known for patients who presented on occasions Table 2 which was used for the logistic regression analysis. Clinical features, outcomes and treatment of patients with promethazine ingestion.
The median age of the 57 patients ingesting promethazine alone was 22 years [inter-quartile range IQR : 17—31 years, range: 3—70] Table 1. The median ingested dose was mg IQR: — mg; range: 25— mg and this was similar to the group including co-ingestants as a whole median mg, IQR: — mg; range: 10— mg.
Reported dose ingested for the four ventilated cases was , , and mg. Inotropic support was not required and there were no reported ECG changes or dysrhythmias apart from tachycardia. Only on three occasions did the GCS fall [one point or greater 15—12, 8—6 and 6—3 ] during the admission, none of which altered clinical management including disposition. Two patients had myoclonus and there were no dystonic reactions, cases of neuroleptic malignant syndrome, seizures or deaths.
In the group of patients who ingested promethazine with co-ingestants Table 1 , there were three single or multiple tonic-clonic seizures.
In one patient this was due to hypoglycaemia from co-ingestants. In another patient who ingested promethazine mg in addition to sertraline and pericyazine the seizure occurred h post ingestion, the cause of which is uncertain. The final patient ingested promethazine mg and paracetamol 5 g and had a seizure 5-h post ingestion. Promethazine appears to be the most likely cause in this presentation. In the co-ingestant group there were no dysrhythmias apart from tachycardia or deaths.
For the group of promethazine alone presentations where dose ingested of promethazine was known, the median ingested dose for promethazine alone presentations with delirium was mg IQR: — mg compared with mg IQR: — mg in those not developing delirium.
Complete information on specific treatments was only available for the latter half of the year period of the study onwards. Univariate analysis was undertaken to explore the association between the dichotomous independent variables and the occurrence of delirium, which is presented in Table 3. This suggests that charcoal within 1 or 2 h, and any co-ingestant or benzodiazepine co-ingestant is associated with a decreased risk of delirium.
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