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Category: Medical

Topic: Pharmacology

Level: AEMT

Next Unit: Herbal Preparations and Supplements

10 minute read

Drugs that have noteworthy risks and possible toxicity or that don’t mix well with other drugs are only allowed by prescription, which assumes a professional healthcare provider licensed to prescribe them oversees the therapeutic process.

Over-the-counter medications (OTC), however, are medications for which the indication is common enough and the risks associated with OTC distribution are low enough to not require a doctor's prescription to purchase them.

Mostly, medicines that have an overwhelming safety record, have been proven effective, and whose directions any person can reasonably understand are allowed to be OTC. As such, the real criterium, besides safety, is in the labeling.

Besides safety, side effects, abuse potential, and overall risk, a drug can be made prescription-only because of its dose.

For example, ibuprofen 200 mg is OTC, whereas ibuprofen 800 mg is by prescription because at this dose the risks start to weigh more heavily against the benefits and the bar on indication vs risk is raised, requiring professional healthcare supervision.


The Most Common OTC Medications

  • Pain relief: acetaminophen, ibuprofen (Advil, Motrin), aspirin.
  • Cold and flu: dextromethorphan, Dimetapp, Contac, Benylin, Neo-Citran, Robitussin.
  • Allergy and sinus: Allegra, Benadryl, Claritin, Sinutab.
  • Heartburn: Zantac, Alka Seltzer.
  • Stomach and digestive health, diarrhea and constipation: Benefibre, Colace, Digesta, docusate, Ex-Lax, Maalox, Milk of Magnesia, Pepto Bismol, Restoralax.
  • Caffeine is a common ingredient in many OTCs.


In the Field

In the field, your most frequent concerns over OTCs are children and with those making suicide attempts. By the very criteria under which OTCs can be non-prescription, complications arising from mixing them with prescriptions drugs are rare (e.g., mixing aspirin with other anticoagulants).

OTC cough and cold medications contain a variety of active ingredients including

  • acetaminophen,
  • antihistamines,
  • dextromethorphan,
  • decongestants (e.g., alpha-adrenergic agonists such as phenylephrine or pseudoephedrine), and
  • ethanol.

These medications frequently cause significant toxicity in children younger than six years of age and are easy choices for those attempting to commit suicide or overdose from suicidal "cries for help."

ANTIHISTAMINES: e.g., chlorpheniramine, brompheniramine, doxylamine, or diphenhydramine)

  • Flushed, dry skin,
  • hyperthermia,
  • dilated pupils,
  • agitation, tremor,
  • picking movements,
  • delirium,
  • hallucinations,
  • coma,
  • seizures.

ALPHA-1 ADRENERGIC DECONGESTANTS, e.g., phenylephrine, pseudoephedrine:

  • hypertension,
  • tachycardia or reflex bradycardia,
  • mydriasis,
  • diaphoresis,
  • agitation.

ALPHA-2 ADRENERGIC DECONGESTANTS and local vasoconstrictors of nasal mucosa, usually not a problem taken nasally, but orally can produce

  • lethargy,
  • coma,
  • apnea,
  • bradycardia,
  • hypotension, and
  • hypothermia.

ANTIPYRETICS AND ANALGESICS, e.g., acetaminophen or ibuprofen

  • nausea, vomiting, lethargy, acutely.
  • Chronic toxicity leads to liver failure.R

Rapid identification of acute acetaminophen overdose is essential because the antidote, N-acetylcysteine (NAC), is most effective when given within eight to 10 hours of an acute acetaminophen ingestion.

COUGH SUPPRESSANT (typically dextromethorphan)

  • euphoria,
  • hallucinations,
  • laughing,
  • agitation,
  • tachycardia,
  • dilated pupils and nystagmus,
  • diaphoresis,
  • coma, and
  • "zombie-like" ataxic gate.

Dextromethorphan is often abused recreationally.

CAMPHOR (oral ingestion or extensive inhalation of topical application)

  • seizures,
  • nausea, vomiting,
  • abdominal pain,
  • agitation,
  • confusion,
  • hyperreflexia,
  • lethargy, and
  • coma.

EXPECTORANT, e.g., guaifenesin

  • dizziness,
  • drowsiness,
  • headache,
  • nausea, vomiting,
  • stomach pain,
  • hypouricemia, and--rarely--
  • nephrolithiasis.

ETHANOL (adult formulations)

  • symptoms of alcohol intoxication.


Need for Rapid Transport

Needless to say, many toxicities overlap their spectra of signs and symptoms, and any of the above does not call for the EMS responder to diagnose the agent, although a history will usually identify it. WHAT IS IMPORTANT, HOWEVER, IS...

  • support,
  • maintenance of ABC (airway, breathing, circulation),
  • IV access, and
  • oxygen if indicated.

In addition to the time-sensitive nature of the overdose emergency, there is additional emphasis on a timely response for acetaminophen overdose, as the antidote is best when given early.

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