Inhalants Clinical Presentation

Many children abuse inhalants regularly; however, only those who develop complications are likely to present to the emergency department or primary care physician. The clinician, especially the primary care physician, must therefore maintain a high index of suspicion for inhalant abuse in any patient presenting with unexplained and often vague complaints.

In the emergency department setting, the acutely intoxicated patient most frequently arrives by ambulance, with the police, or with friends and family. In obtaining the history, ask prehospital personnel about empty chemical or spray containers found at the scene. Ask about rags, cloths, or strange smells about the patient. Also inquire about the possibility of co-ingestion, suggested by pill bottles found at the scene.

As inhalant abuse is typically a group activity, elicit a history from friends or family who were present. Discuss with parents changes in behavior or school performance, new groups of friends, or new types of social activities that might suggest use of these drugs. Strongly suspect inhalant abuse in the setting of sudden collapse during adolescent group activities. Occult trauma is common in these patients, as lost inhibition leads to dangerous activities during intoxication.

The clinical history can be broken down into acute intoxication, chronic inhalation use, and withdrawal syndrome.

• Acute intoxication - most symptoms resolve within 2 hours

  • In acute intoxication, neurologic, cardiac, and pulmonary symptoms predominate.
  • Acute neurologic symptoms resemble alcohol intoxication and include euphoria, slurred speech, ataxia, dizziness, diplopia, confusion, and CNS depression. Potential acute effects include headache, vertigo, auditory and visual hallucinations, seizures, stupor, and coma
  • Acute cardiac effects include heart palpitations and tachycardia.
  • Pulmonary symptoms are due to asphyxiation and direct lung damage producing pneumonitis. In the history, inquire about dyspnea, wheezing, and coughing. Cyanosis of the extremities can develop secondary to methemoglobinemia associated with alkyl nitrite abuse and can produce skin discoloration and cyanosis.
• Chronic abuse

  • In chronic inhalant abuse, irreversible CNS complications can occur, including cerebral cortex atrophy, cerebellar degeneration, peripheral neuropathy, and neuropsychosis, leading to cognitive function decline, dementia, gait disturbances, and loss of coordination. Neurologic signs and symptoms to elicit include peripheral neuropathies (typically stocking-glove distribution), seizures, paresthesias, ataxia, weakness, confusion, memory loss, and delusions.
  • Long-term exposure can also lead to cranial nerve damage, causing optic neuropathy and blindness, tinnitus, and sensorineural hearing loss.
  • Chronic renal injury from inhalant use includes type I renal tubular acidosis, urinary calculi, and glomerulonephritis and typically produces flank pain, clouding of the urine, and decreased urine production with azotemia.
  • Toxic hepatitis and liver failure has also been seen in chronic users of chlorinated hydrocarbons by damage of toxic metabolites. The history may reveal symptoms of right upper quadrant abdominal pain, nausea, vomiting, low-grade fever, fatigue, or jaundice.
  • Rhabdomyolysis and severe muscle weakness, similar to Guillain-Barr é syndrome , has also been reported.
• Withdrawal symptoms

  • These symptoms include tremors, irritability, anxiety, insomnia, delirium, tingling sensations, seizures, and muscle cramps. If tolerance has developed, complaints of chills, headache, muscle cramps, and vague abdominal pain should be elicited.
  • These patients present with sleep disturbance, tremor, nausea, irritability, and abdominal pain. Withdrawal symptoms are worse during the period 2-5 days after inhalant cessation. Patients may present with symptoms similar to delirium tremens.

If the inhalant abuse patient is pregnant, special considerations need to be taken. Although well-controlled prospective data have not been collected, current information suggests adverse effects of maternal inhalant abuse on the fetus. Because of high lipophilicity, these solvents readily cross the placenta and cause fetal anomalies, including microcephaly, narrow bifrontal diameter, hypoplastic midface, and blunt fingertips. This syndrome closely resembles the physical findings of fetal alcohol syndrome. Increased rates of spontaneous abortion and fetal malformations have been reported, as have growth retardation and deficits in both speech and cognitive skills.

• Skin

  • Paint or stains on the face, hands, or clothing This young man was huffing green spray paint. Note the presence of the paint on his hands and face. This picture shows a close-up of the face of a young man who had been huffing green spray paint.
  • "Huffer rash" - Erythematous "frost bite" eruption on the face and oral mucosa caused by severe drying and cracking of the skin and resultant bacterial infection
  • Thermal or chemical burns on the face or hands
  • Conjunctival injection
  • Jaundice (with chronic hepatic injury)
  • Cyanosis (with methemoglobinemia)
• Respiratory

  • Chemical odor in the breath
  • Wheezing, rhonchi, or rales
  • Oral or airway burns
  • Rhinitis
  • Respiratory distress with aspiration of gastric contents
• Neurologic/psychiatric

  • Slurred speech
  • Diplopia
  • Blurred vision
  • Nystagmus
  • Euphoria
  • Psychomotor retardation
  • Disorientation
  • Sense of invulnerability
  • Distortion of space and time
  • Auditory or visual hallucinations with paranoid ideations
  • Photophobia
  • Weakness
  • Impaired memory
  • Peripheral neuropathy (typically stocking-glove distribution)
  • Seizures
  • Agitated coma (unconsciousness with tremors, restlessness, and hyperreflexia)
• Cardiac

  • Arrhythmias, including premature ventricular contractions (PVCs) or supraventricular tachycardia (SVT)
  • Tachycardia or bradycardia
  • Hypotension
• Gastrointestinal tract

  • Nausea and vomiting
  • Diarrhea
  • Abdominal pain (suspect hepatic injury if the pain is in the right upper quadrant, especially in a chronic abuser)
  • Flank pain (suspect renal injury in chronic abusers)

The cause of inhalational injury is the use of inhalation agents. As described earlier, this use is affected by many factors such as age and socioeconomic status (see Frequency and Mortality/Morbidity).