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Volatile Inhalant

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Volatile Inhalant, Inhalation Drug Use, Inhalant Abuse, Volatile Inhalant Abuse, Sudden Sniffing Death Syndrome, Huffing

  • Epidemiology
  1. Common abuse in 10-14 years old (easy access to household inhalants)
  • Forms
  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
  • Mechanism
  • Methods of abuse
  1. Sniffing
    1. Inhaling substance from container (e.g. sniffing glue)
  2. Huffing
    1. Rag soaked in agent placed over nose, mouth
  3. Bagging
    1. Substance poured into a bag and inhaled
    2. Most dangerous method of Inhalant Abuse due to combination with anoxia and hypercarbia
  • Symptoms
  • 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 (with chronic use)
      1. Dominant hand erythematous compared with opposite hand
  5. Eye signs
    1. Conjunctival injection
    2. Mydriasis
  6. 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
  7. Pulmonary
    1. Spontaneous Pneumothorax (associated with Nitrous Oxide inhalation)
  • 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
    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. Muscle Weakness
    7. Panacinar Emphysema
    8. Goodpasture's Syndrome
    9. Permanent cognitive deficits
    10. Ataxia
    11. Pregnancy complications
      1. Intrauterine Growth Retardation
      2. Perinatal death
  3. Inhaled Hydrocarbons
    1. Fatal cardiac arrhythmias
  4. Pregnancy related fetal affects
    1. Spontaneous Abortion
    2. Fetal Solvent Syndrome
      1. Similar to Fetal Alcohol Syndrome
  • 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]
  • 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 (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)
  • Diagnostics
  1. Electrocardiogram (immediately)
  2. Continuous cardiac monitoring (for arrhythmia)
  3. Oxygen Saturation
  4. Chest XRay
    1. Pneumothorax
    2. Chemical pneumonitis
  • Management
  • Toxicity
  1. Supportive care
  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. No known antidote
  7. Discharge Criteria
    1. No arrhythmia and
    2. Normal exam, labs and diagnostics and
    3. Observation for 4-6 hours
  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
  • Complications
  1. Sudden Sniffing Death Syndrome (see above)
  2. Asphyxia
  3. Aspiration
  4. Methemoglobinemia
  5. Pneumothorax
  • References
  1. Swadron and Nordt in Herbert (2017) EM:Rap 17(7): 14
  2. Swadron and Nordt in Herbert (2013) EM:Rap 13(7): 7
  3. Anderson (2003) Am Fam Physician 68(5):869-74 [PubMed]
  4. Brouette (2001) Am J Addict 10:79-94 [PubMed]