II. Epidemiology
- Common abuse in 10-14 years old (easy access to household inhalants)
III. Preparations
- Organic Nitrites (e.g. Amyl Nitrite)
-
Nitrous Oxide ("Laughing Gas")
- Also found in aerosol bottles (see below)
- Gasoline, Propane, or other Hydrocarbons
- Butane (lighter fluid, hair spray, deodorants)
- Propane (Gas grill fuel, room freshener, spray paint)
- Fluorocarbons (Asthma or Analgesic spray, Freon gas)
- Chlorinated Hydrocarbons (dry-cleaning, spot remover)
- Solvents (Thinners)
- Toluene (Paint thinner, glue, nail polish remover)
- Acetone (Nail polish remover, permanent markers)
- Trichloroethylene
- Perchlorethylene
- Other common agents with inhalants
- Paint Aerosols
- Whipped cream aerosol (e.g. Whippet)
- Cleaning fluid (e.g. keyboard cleaner, Dust-Off)
- Correction fluid
- Shoe polish
IV. Mechanism: Methods of abuse
- Background
- Duration of action: Short (e.g. 10 minutes)
- Sniffing
- Inhaling substance from container (e.g. sniffing glue)
- Huffing
- Rag soaked in agent placed over nose, mouth
- Bagging
- Substance poured into a bag and inhaled
- Most dangerous method of Inhalant Abuse due to combination with anoxia and hypercarbia
V. Symptoms: Desired Effects (Reason for Use)
- Euphoria
- Dizziness
- CNS Depression
VII. Findings: Signs and Symptoms
- See Substance Abuse Evaluation
-
General observation
- Staining of clothes
- Chemical inhalant odor to breath
- Room with multiple inhalant cans (e.g. air fresheners)
- Mouth and nose changes
- Perioral lesions, discoloration, erythema or "de-fatting" (with chronic use)
- Rhinorrhea
- Dominant hand changes
- Staining of Fingernails or skin
- De-fatting of dominant hand ("Huffer's Eczema" with chronic use)
- Dominant hand erythematous compared with opposite hand
- Eye signs
- Conjunctival injection
- Mydriasis
- Cardiovascular
- Pulmonary
- Spontaneous Pneumothorax (associated with Nitrous Oxide inhalation)
- Acute Hypoxia, Dyspnea
- Pneumonitis
- Neuromuscular
- Nystagmus
- Diplopia
- Lethargy
- Slurred Speech
- Disorientation
- Altered Level of Consciousness
- Mood instability
- Ataxia
- Impaired memory
VIII. Signs: Toxicity
-
General
- Ataxia
- Laryngospasm
- Respiratory depression
- Coma
- Permanent cerebral changes
- Imaging changes (atrophy, white matter loss)
- Cognitive deficits (Dementia, encephalopathy)
- Peripheral Neuropathy
- Marrow toxicity (Leukopenia, Thrombocytopenia, Anemia)
- Hepatic toxicity
- Renal toxicity
- Cardiac toxicity with Arrhythmia risk (including Ventricular Fibrillation)
- Most associated with the inhaled Hydrocarbons
- Suffocation when used with plastic bag
- Toluene (paint, lacquer, or glue)
- Hypokalemia
- Hypophosphatemia
- Renal Tubular Acidosis (RTA)
- Metabolic Acidosis
- Typically hyperchloremic Non-Anion Gap Metabolic Acidosis
- Anion Gap Metabolic Acidosis can occur due to toluene toxic metabolite
- Abdominal Pain
- Panacinar Emphysema
- Goodpasture's Syndrome
- Permanent cognitive deficits
- Ataxia
- Pregnancy complications
- Intrauterine Growth Retardation
- Perinatal death
- Carbon Tetrachloride
- Hepatitis
- Methylene Chloride
- Carbon Monoxide Poisoning via metabolism of methylene chloride
- Inhaled Hydrocarbons
- Fatal Cardiac Arrhythmias
- Fluorinated Hydrocarbons
- Perioral freeze burns from expanding gases
- Pregnancy related fetal affects
- Spontaneous Abortion
- Fetal Solvent Syndrome
- Similar to Fetal Alcohol Syndrome
IX. Complications: Sudden Sniffing Death Syndrome
- Responsible for 50% of inhalant-related deaths
- Mechanism
- Sudden Catecholamine release with sympathetic surge
- Hydrocarbons block Potassium channels resulting in QT Prolongation
- Provokes lethal Arrhythmias (e.g. Ventricular Tachycardia)
- Management (if presents early enough for intervention)
- Reference
X. Labs
-
Aliphatic hydrocarbon testing by gas chromatography
- Obtain sample in EDTA or Heparin tube
- Urine toxicologic screening
- Screen for other concurrent ingestions
- Acute toxicity evaluation
- Complete Blood Count (CBC)
- Comprehensive metabolic panel
- Liver Function Tests, Renal Function tests, Electrolyte panel with Serum Calcium
- Serum Phosphorus
- Creatinine Phosphokinase (CPK)
- Arterial Blood Gas (ABG) or Venous Blood Gas (VBG)
XI. Diagnostics
- Electrocardiogram (immediately)
- Continuous cardiac monitoring (for Arrhythmia)
- Oxygen Saturation
-
Chest XRay
- Pneumothorax
- Chemical pneumonitis
XII. Management: Toxicity
- Supportive care
- ABC Management
- Continuous cardiac monitor while symptoms persist
- Evaluate Altered Level of Consiousness
- Avoid Epinephrine (and other arrhythmogenics)
- Administer Beta Blocker early in course
- Prevents Catecholamine induced Arrhythmias
- Propranolol has been historically used (but long acting and any Beta Blocker can be used)
- Esmolol infusion should be considered instead for titration and fast on and off activity
- However must be monitored very closely for Hypotension and Bradycardia
- Correct acid-base status
- Correct elecrolyte imbalances
- No known antidote
- No Decontamination or elimination protocols are effective
- Discharge Criteria
- No Arrhythmia and
- Normal exam (baseline mental status, no cardiopulmonary complications) and
- Normal labs and diagnostics and
- Observation for 4-6 hours
XIII. Management: Chemical Dependency
- Chemical Dependency Treatment Programs
- Supportive care for withdrawal symptoms (uncommon)
- Withdrawal symptoms may persist for >1 month
- Symptoms may mimic Alcohol Withdrawal
XIV. Complications
- Sudden Sniffing Death Syndrome (see above)
- Asphyxia
- Aspiration
- Methemoglobinemia
- Pneumothorax
XV. References
- Corbett and Tomaszewski (2017) Crit Dec Emerg Med 31(7): 24
- Swadron and Nordt in Herbert (2017) EM:Rap 17(7): 14
- Swadron and Nordt in Herbert (2013) EM:Rap 13(7): 7
- Anderson (2003) Am Fam Physician 68(5):869-74 [PubMed]
- Brouette (2001) Am J Addict 10:79-94 [PubMed]