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.