eMedicine Specialties > Neurology > Neurotoxicology

Inhalants: Differential Diagnoses & Workup

Author: Timothy Kaufman, MD, Staff Physician, Department of Emergency Medicine, Covenant Hospital, Saginaw Michigan
Coauthor(s): Edward C Jauch, MD, Faculty, Greater Cincinnati/Northern Kentucky Stroke Team, Associate Director of Research, Department of Emergency Medicine, Assistant Professor, University of Cincinnati College of Medicine; Rhonda S Cadena, MD, Staff Physician, Department of Emergency Medicine, University of Cincinnati College of Medicine
Contributor Information and Disclosures

Updated: Jul 9, 2007

Differential Diagnoses

Alcohol (Ethanol) Related Neuropathy
Methanol
Cerebral Venous Thrombosis
Organic Solvents
Cocaine
Psychiatric Disorders Associated With Epilepsy
Confusional States and Acute Memory Disorders
Thyroid Disease
Epidural Hematoma
Head Injury
Inhalants

Other Problems to Be Considered

Alcohol (ethanol)-related syndromes
Arrhythmia
Asphyxiation
Ataxia
Carbon monoxide poisoning
Cyanide poisoning
Delirium
Diabetic ketoacidosis
Drug effects (anticholinergic, antiepileptic, antidepressants, antipsychotics, antiparkinsonians, anxiolytics, opiates)
Ethanol
Infectious diseases
Marijuana
Metabolic abnormalities
Phencyclidine
Psychosis and other psychiatric diseases
Substance abuse
Sudden death
Trauma, evident or occult

Workup

Laboratory Studies

  • As with every patient, the laboratory workup depends upon the severity of the illness. For anything more severe than mild intoxication, the following tests are generally recommended:
    • Pulse oximetry: Pulse oximetry assesses the degree of oxygenation and general state of pulmonary effort and function.
    • Serum chemistry: Analyses should include a standard renal panel including sodium, potassium, chloride, bicarbonate, BUN, and creatinine. Some of the inhalants, toluene in particular, cause a syndrome of distal renal tubular acidosis, with a resultant elevated anion gap, hyperchloremia, hypokalemia, and hypophosphatemia. Azotemia is also common with chronic exposure but resolves with abstinence. Hypoglycemia may be noted.
    • Arterial blood gases (ABGs): This study can be helpful in cases of inhalant intoxication. Significant acidosis, hypoxemia, or hypercarbia may suggest the need for patient intubation.
    • Complete blood count (CBC): CBC is useful as a routine screening laboratory test. Chronic users may exhibit bone marrow suppression, thrombocytopenia, and aplastic anemia.
    • Urinalysis: Elevated urobilinogen suggests hepatic involvement. Hyaline casts, elevated white blood cell counts, elevated red blood cell counts, or abnormal glucose and protein levels may suggest renal injury.
    • Creatine phosphokinase (CPK): Useful in patients with muscle tenderness or myoglobinuria to evaluate the presence of rhabdomyolysis.
    • Serum or urine toxicology: Toxicology screens may be helpful if the specific chemical involved is unknown. Specific toxicologic tests of inhalant agents are not readily available in all laboratories and may take several days to weeks to get results so they are not helpful in the immediate diagnosis. Consult with the laboratory regarding their ability to test for specific agents.
    • Pregnancy testing should be done in all solvent-abusing females because of the risk of embryopathy caused by these agents.

Imaging Studies

  • Imaging studies can be useful adjuncts to the history, physical, and laboratory evaluation. Suggested studies include chest x-ray films and head CT scan.
    • Chest radiograph: This study helps identify the etiology of respiratory difficulties associated with inhalant abuse. These include pneumothorax, aspiration pneumonia, or chemical pneumonitis with patchy or diffuse infiltrates. Chronic abusers with subsequent cardiomegaly might exhibit enlarged heart size and pulmonary edema.
    • Head CT scan: If occult trauma is suspected in the inhalant abuse patient, be liberal with CT scanning to rule out intracranial hemorrhage and occult fractures. Chronic abusers may show signs of cerebral or cerebellar atrophy.

Other Tests

  • ECG/cardiac monitoring: Many inhalants are proarrhythmic; therefore, acutely intoxicated patients should have continuous ECG monitoring. ECG often show tachycardia, bradycardia, arrhythmias, or even cardiac ischemia with solvent abuse.

Procedures

  • Follow advanced cardiac life support (ACLS) guidelines.
  • Consider oral or tracheal intubation in any patient with significantly decreased level of consciousness, inability to protect the airway, or severe oropharyngeal thermal injury secondary to inhalation.
  • Obtain peripheral or central intravenous (IV) access in all patients with suspected significant intoxication.
  • Cardioversion may be necessary if ventricular arrhythmias are present.

More on Inhalants

Overview: Inhalants
Differential Diagnoses & Workup: Inhalants
Treatment & Medication: Inhalants
Follow-up: Inhalants
Multimedia: Inhalants
References
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References

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Further Reading

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Keywords

sniffing, huffing, bagging, inhaling, solvents, aerosols, adhesives, fuels, dry-cleaning agents, tape-head cleaners, correction fluid, propellants, inhalant abuse, volatile chemicals, alkyl nitrites, aromatics, benzene, methylene chloride, inhalant intoxication, inhalant agents

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Contributor Information and Disclosures

Author

Timothy Kaufman, MD, Staff Physician, Department of Emergency Medicine, Covenant Hospital, Saginaw Michigan
Timothy Kaufman, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Edward C Jauch, MD, Faculty, Greater Cincinnati/Northern Kentucky Stroke Team, Associate Director of Research, Department of Emergency Medicine, Assistant Professor, University of Cincinnati College of Medicine
Edward C Jauch, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, American Medical Association, National Stroke Association, Ohio State Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Rhonda S Cadena, MD, Staff Physician, Department of Emergency Medicine, University of Cincinnati College of Medicine
Rhonda S Cadena, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Medical Editor

Jonathan S Rutchik, MD, MPH, Assistant Professor, Department of Occupational and Environmental Medicine, University of California at San Francisco
Jonathan S Rutchik, MD, MPH is a member of the following medical societies: American Academy of Neurology and Association of American Physicians and Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor of Neurology, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida College of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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