II. Epidemiology

  1. Common abuse in 10-14 years old (easy access to household inhalants)

III. Preparations

  1. Organic Nitrates
  2. Nitrous Oxide ("Laughing Gas")
    1. Also found in aerosol bottles (see below)
  3. Gasoline, Propane, or other Hydrocarbons
    1. Butane (lighter fluid, hair spray, deodorants)
    2. Propane (Gas grill fuel, room freshener, spray paint)
    3. Fluorocarbons (Asthma or Analgesic spray, Freon gas)
    4. Chlorinated Hydrocarbons (dry-cleaning, spot remover)
  4. Solvents (Thinners)
    1. Toluene (Paint thinner, glue, nail polish remover)
    2. Acetone (Nail polish remover, permanent markers)
    3. Trichloroethylene
    4. Perchlorethylene
  5. Other common agents with inhalants
    1. Paint Aerosols
    2. Whipped cream aerosol (e.g. Whippet)
    3. Cleaning fluid (e.g. keyboard cleaner, Dust-Off)
    4. Correction fluid
    5. Shoe polish

IV. Mechanism: Methods of abuse

  1. Background
    1. Duration of action: Short (e.g. 10 minutes)
  2. Sniffing
    1. Inhaling substance from container (e.g. sniffing glue)
  3. Huffing
    1. Rag soaked in agent placed over nose, mouth
  4. Bagging
    1. Substance poured into a bag and inhaled
    2. Most dangerous method of Inhalant Abuse due to combination with anoxia and hypercarbia

V. Symptoms: Desired Effects (Reason for Use)

  1. Euphoria
  2. Dizziness
  3. CNS Depression

VI. Symptoms: Adverse

VII. Findings: Signs and Symptoms

  1. See Substance Abuse Evaluation
  2. General observation
    1. Staining of clothes
    2. Chemical inhalant odor to breath
    3. Room with multiple inhalant cans (e.g. air fresheners)
  3. Mouth and nose changes
    1. Perioral lesions, discoloration, erythema or "de-fatting" (with chronic use)
    2. Rhinorrhea
  4. Dominant hand changes
    1. Staining of Fingernails or skin
    2. De-fatting of dominant hand ("Huffer's Eczema" with chronic use)
      1. Dominant hand erythematous compared with opposite hand
  5. Eye signs
    1. Conjunctival injection
    2. Mydriasis
  6. Cardiovascular
    1. Palpitations
    2. Syncope
  7. Pulmonary
    1. Spontaneous Pneumothorax (associated with Nitrous Oxide inhalation)
    2. Acute Hypoxia, Dyspnea
    3. Pneumonitis
  8. Neuromuscular
    1. Nystagmus
    2. Diplopia
    3. Lethargy
    4. Slurred Speech
    5. Disorientation
    6. Altered Level of Consciousness
    7. Mood instability
    8. Ataxia
    9. Impaired memory

VIII. Signs: Toxicity

  1. General
    1. Ataxia
    2. Laryngospasm
    3. Respiratory depression
    4. Coma
    5. Permanent cerebral changes
      1. Imaging changes (atrophy, white matter loss)
      2. Cognitive deficits (Dementia, encephalopathy)
      3. Peripheral Neuropathy
    6. Marrow toxicity (Leukopenia, Thrombocytopenia, Anemia)
    7. Hepatic toxicity
    8. Renal toxicity
      1. Renal Tubular Acidosis
      2. Fanconi's Syndrome
      3. Acute Renal Failure
    9. Cardiac toxicity with Arrhythmia risk
    10. Suffocation when used with plastic bag
  2. Toluene (paint, lacquer, or glue)
    1. Hypokalemia
      1. Muscle Weakness
    2. Hypophosphatemia
    3. Renal Tubular Acidosis (RTA)
    4. Metabolic Acidosis
      1. Typically hyperchloremic Non-Anion Gap Metabolic Acidosis
      2. Anion Gap Metabolic Acidosis can occur due to toluene toxic metabolite
    5. Abdominal Pain
    6. Panacinar Emphysema
    7. Goodpasture's Syndrome
    8. Permanent cognitive deficits
    9. Ataxia
    10. Pregnancy complications
      1. Intrauterine Growth Retardation
      2. Perinatal death
  3. Carbon Tetrachloride
    1. Hepatitis
  4. Methylene Chloride
    1. Carbon Monoxide Poisoning via metabolism of methylene chloride
  5. Inhaled Hydrocarbons
    1. Fatal Cardiac Arrhythmias
  6. Fluorinated Hydrocarbons
    1. Perioral freeze burns from expanding gases
  7. Pregnancy related fetal affects
    1. Spontaneous Abortion
    2. Fetal Solvent Syndrome
      1. Similar to Fetal Alcohol Syndrome

IX. Complications: Sudden Sniffing Death Syndrome

  1. Responsible for 50% of inhalant-related deaths
  2. Mechanism
    1. Sudden Catecholamine release with sympathetic surge
    2. Hydrocarbons block Potassium channels resulting in QT Prolongation
    3. Provokes lethal Arrhythmias (e.g. Ventricular Tachycardia)
  3. Management (if presents early enough for intervention)
    1. Administer Magnesium
    2. Standard ACLS protocols
  4. Reference
    1. Bass (1970) JAMA 212:2075-9 [PubMed]

X. Labs

  1. Aliphatic hydrocarbon testing by gas chromatography
    1. Obtain sample in EDTA or Heparin tube
  2. Urine toxicologic screening
    1. Screen for other concurrent ingestions
  3. Acute toxicity evaluation
    1. Complete Blood Count (CBC)
    2. Comprehensive metabolic panel
      1. Liver Function Tests, Renal Function tests, Electrolyte panel with Serum Calcium
    3. Serum Phosphorus
    4. Creatinine Phosphokinase (CPK)
    5. Arterial Blood Gas (ABG) or Venous Blood Gas (VBG)

XI. Diagnostics

  1. Electrocardiogram (immediately)
  2. Continuous cardiac monitoring (for Arrhythmia)
  3. Oxygen Saturation
  4. Chest XRay
    1. Pneumothorax
    2. Chemical pneumonitis

XII. Management: Toxicity

  1. Supportive care
    1. ABC Management
    2. Continuous cardiac monitor while symptoms persist
  2. Evaluate Altered Level of Consiousness
  3. Avoid Epinephrine (and other arrhythmogenics)
  4. Administer Beta Blocker early in course
    1. Prevents Catecholamine induced Arrhythmias
    2. Propranolol has been historically used (but long acting and any Beta Blocker can be used)
    3. Esmolol infusion should be considered instead for titration and fast on and off activity
      1. However must be monitored very closely for Hypotension and Bradycardia
  5. Correct acid-base status
  6. Correct elecrolyte imbalances
  7. No known antidote
  8. No Decontamination or elimination protocols are effective
  9. Discharge Criteria
    1. No Arrhythmia and
    2. Normal exam (baseline mental status, no cardiopulmonary complications) and
    3. Normal labs and diagnostics and
    4. Observation for 4-6 hours

XIII. Management: Chemical Dependency

  1. Chemical Dependency Treatment Programs
  2. Supportive care for withdrawal symptoms (uncommon)
    1. Withdrawal symptoms may persist for >1 month
    2. Symptoms may mimic Alcohol Withdrawal

XIV. Complications

  1. Sudden Sniffing Death Syndrome (see above)
  2. Asphyxia
  3. Aspiration
  4. Methemoglobinemia
  5. Pneumothorax

XV. References

  1. Corbett and Tomaszewski (2017) Crit Dec Emerg Med 31(7): 24
  2. Swadron and Nordt in Herbert (2017) EM:Rap 17(7): 14
  3. Swadron and Nordt in Herbert (2013) EM:Rap 13(7): 7
  4. Anderson (2003) Am Fam Physician 68(5):869-74 [PubMed]
  5. Brouette (2001) Am J Addict 10:79-94 [PubMed]

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Related Studies

Ontology: Inhalant Abuse (C0021449)

Definition (MSH) Illicit use of chemicals and products whose vapors can be inhaled to produce a rapid mind-altering effect. Inhalants include aerosols, gases, and volatile solvents that are often inhaled repeatedly to achieve the short-lived intoxicating effect.
Definition (PSY) Inhalation of vapors from volatile chemical substances (such as aerosol sprays, solvents, and anesthetics) in order to produce mind-altering effects.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D058545
ICD10 F18.1
SnomedCT 70340006
DSM4 305.90
English inhalant abuse (diagnosis), inhalant abuse, Abuse, Inhalant, Inhalant Abuses, Abuses, Inhalant, abuse inhalant, abuse inhalants, Inhalant Abuse [Disease/Finding], Inhalant abuse, Inhalant abuse (disorder), inhalant; abuse, abuse; inhalant, Inhalant Abuse
French Sniffage (toxicomanie), Abus de produits à inhaler, Abus d'inhalants, Sniffing (toxicomanie)
German Schnueffel-Sucht, Schnüffel-Sucht
Italian Inalazione di colle, Abuso di inalanti
Spanish Abuso de Inhalantes, abuso de inhalantes (trastorno), abuso de inhalantes
Portuguese Abuso de Inalantes, Inalação de Cola
Polish Uzależnienie od inhalantów, Uzależnienie od substancji wziewnych, Nadużywanie substancji wziewnych, Wąchanie kleju, Nałóg inhalantów, Wdychanie środków odurzających, Odurzanie się wziewne
Czech čichání psychoaktivních látek
Norwegian Sniffing, Misbruk av flyktige løsemidler
Dutch inhalantia; misbruik, misbruik; inhalantia

Ontology: Volatile solvent-based substance of abuse - non-pharmaceutical (C0565920)

Concepts Hazardous or Poisonous Substance (T131)
SnomedCT 228989008
English Vol solv subst abuse non-pharm, Volatile solvent-based substance of abuse - non-pharmaceutic, Volatile solvent-based substance of abuse - non-pharmaceutical, Volatile solvent-based substance of abuse - non-pharmaceutical (substance)
Spanish sustancia de abuso en base a solvente volátil - no farmacéutica (sustancia), sustancia de abuso en base a solvente volátil - no farmacéutica