Instantaneous rigor after fatal pholcodine intoxication

Pholcodine is a commonly used antitussive medication. In France, its use is limited because of the risk of an allergic cross-reaction with curare. Here we report the case of a 52-year-old man who ingested 750 mg of pholcodine syrup. An emergency medical team found him at home in nonshockable cardiac arrest. Orotracheal intubation was impossible because of instantaneous rigor associated with trismus, so an emergency cricothyrotomy was performed. Return of spontaneous circulation was obtained 5 min later. Cardiac arrest recurred upon arrival at the intensive care unit, leading to death. Toxicological analysis showed a pholcodine blood level of 2500 ng ml−1 (a lethal dose is >1000 ng ml−1, extrapolated from animal studies). Pholcodine is an opioid derivate with a central antitussive effect that is indicated for unproductive cough in adults. No case of fatal intoxication has ever been reported. We hypothesize that cardiac arrest was the result of hypoxia due to respiratory arrest connected to the opioid nature of pholcodine. Interestingly, instantaneous rigor occurred, which should be not confused with rigor mortis. Instantaneous rigor is a rarely reported condition that persists until rigor mortis and disappears in the stage of secondary flaccidity. Instantaneous rigor can lead to trismus, making orotracheal intubation impossible and necessitating emergency cricothyrotomy. This case shows that pholcodine overdose can be lethal and can lead to instantaneous rigor.