eMedicine Specialties > Neurology > Neurotoxicology

Inhalants: Treatment & Medication

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

Treatment

Medical Care

Appropriate medical care for the inhalant-abusing patient is dictated by the severity of injury and the setting of care. The following medical care is recommended for patients with acute intoxication.

  • Prehospital care: Start by securing the patient's airway, breathing, and circulation. Follow standard ACLS protocols, keeping in mind that inhalant-abuse patients may experience hallucinations and become combative. Restraints should be applied carefully, if at all, and in accordance with local policy. Sufficient personnel should assist with moving the patient to the hospital to ensure the safety of both the patient and the EMS crew. If saturated with solvent, the patient's clothing should be removed to prevent worsening intoxication and to protect EMS personnel. Supply supplemental oxygen and obtain IV access if appropriate.
  • Emergency department care begins by protecting the patient's airway as dictated by level of consciousness and the ability of the patient to control their airway. Intubation may be required, so have appropriate equipment and personnel available. Place the patient on supplemental oxygen. Cautiously treat bronchospasm (if present) with aerosolized beta-agonists, bearing in mind that these agents may induce arrhythmias in the inhalant-sensitized heart. If severe bronchospasm is present, systemic steroids (in doses similar to those used with acute asthma exacerbations) can be helpful.
    • Obtain intravenous access and begin cardiac monitoring. Treat hypotension with supine patient positioning and intravenous fluid boluses. Use catecholamine pressors if necessary, but remember that these agents also cause cardiac sensitization and are proarrhythmic. Severe patient agitation should be treated with benzodiazepines or with haloperidol. Remember that sudden death in these patients often involves sudden or strenuous activity; therefore, minimize patient agitation as much as possible.
    • Measure electrolytes, including potassium, calcium, and phosphorus and replete as necessary because abnormal values can exacerbate cardiac dysrhythmias and muscle weakness.
    • GI decontamination is generally not recommended unless co-ingestion is suspected, in which case, activated charcoal or an electrolyte solution (eg, GoLYTELY) may be indicated.
    • Specific laboratory tests and antidotes may be indicated for the following volatiles:

      • Methylene chloride: Check carboxyhemoglobin level, use 100% nonrebreather oxygen, and consider hyperbaric oxygen treatment for the critically ill. These patients require prolonged monitoring and treatment (at least 12-24 h), because the carbon monoxide level resolves more slowly than in inhaled carbon monoxide poisoning.
      • Alkyl nitrites: Check serum methemoglobin levels. For levels more than 30% in symptomatic patients, administer methylene blue, 1-2 mg/kg IV over 5 minutes; repeat in 30-60 minutes as necessary. Total dose should not exceed 7 mg/kg to prevent a promethemoglobin paradoxical effect.
      • Carbon tetrachloride: Consider hepatic injury and necrosis. Experimental evidence supports use of N -acetyl-cysteine (NAC), charcoal hemoperfusion, and hyperbaric oxygen.
      • Gasoline: Chronic gasoline sniffing formerly was associated with lead poisoning; thus, lead testing might be warranted. Gasoline sold in the United States today is generally unleaded. Check blood lead level if appropriate and treat elevated levels accordingly with chelating agents.

Consultations

  • Consulting a toxicologist or a local poison control center for any acute inhalant intoxication is appropriate and encouraged.
  • A cardiologist should be consulted if ventricular arrhythmias are present and persistent.

Medication

The goals of pharmacotherapy are to neutralize the effects of the toxic chemical, to reduce morbidity, and to prevent complications.

Vasopressors

These drugs augment both coronary and cerebral blood flow present during low flow states.


Dopamine (Intropin)

Indicated for treatment of hypotension or shock after adequate volume replacement and if patient has stable rhythm.

Adult

Initial: 5-10 mcg/kg/min IV; titrate to desired effect; if infusion dose is >20 mcg/kg/min, consider switching to epinephrine or another vasopressor agent

Pediatric

Administer as in adults

Phenytoin, alpha- and beta-adrenergic blockers, general anesthetics, and MAOIs increase and prolong effects

Documented hypersensitivity; inadequate intravascular volume; cardiac arrhythmia

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

High infusion rates may produce peripheral, renal, and splanchnic vasoconstriction and ischemia; may also cause significant tachycardia


Epinephrine (Adrenalin, Bronitin, EpiPen)

Indicated in bolus form for asystole or pulseless arrest; indicated as continuous IV infusion for shock or significant hypotension after ensuring adequate intravascular volume.

Adult

Follow ACLS protocols

Pediatric

Follow PALS protocols

Increases toxicity of beta- and alpha-blocking agents and that of halogenated inhalational anesthetics; do not mix with sodium bicarbonate

Documented hypersensitivity; inadequate intravascular volume; cardiac arrhythmia

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in elderly, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias; as it may cause significant tachycardia, be aware that rising blood pressure and increasing heart rate may cause myocardial ischemia and increase in myocardial oxygen demand

More on Inhalants

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

  1. National Inhalant Prevention Coalition. National Inhalant Prevention Coalition Web site. [Full Text].

  2. American Heart Association. Handbook of Cardiac Care for Healthcare Providers. 1996:50-51, 94-95.

  3. Beauvais F, Oetting ER. Toward a clear definition of inhalant abuse. Int J Addict. Aug 1987;22(8):779-84. [Medline].

  4. Bowen SE, Daniel J, Balster RL. Deaths associated with inhalant abuse in Virginia from 1987 to 1996. Drug Alcohol Depend. Feb 1 1999;53(3):239-45. [Medline].

  5. Bowen SE, Hannigan JH. Developmental toxicity of prenatal exposure to toluene. AAPS J. 2006;8(2):E419-24. [Medline].

  6. Chepesiuk R. Resurgence of teen inhalant use. Environ Health Perspect. Dec 2005;113(12):A808. [Medline].

  7. Dinwiddie SH. Abuse of inhalants: a review. Addiction. Aug 1994;89(8):925-39. [Medline].

  8. Henretig F. Inhalant abuse in children and adolescents. Pediatr Ann. Jan 1996;25(1):47-52. [Medline].

  9. Jones HE, Balster RL. Inhalant abuse in pregnancy. Obstet Gynecol Clin North Am. Mar 1998;25(1):153-67. [Medline].

  10. Linden CH. Volatile substances of abuse. Emerg Med Clin North Am. Aug 1990;8(3):559-78. [Medline].

  11. Lowinson J, Ruiz P. Volatile substances. In: Sharp CW and Rosenberg NL, eds. Substance Abuse. 1992:303-327.

  12. McGarvey EL, Clavet GJ, Mason W, Waite D. Adolescent inhalant abuse: environments of use. Am J Drug Alcohol Abuse. Nov 1999;25(4):731-41. [Medline].

  13. McGuinness TM. Nothing to sniff at: inhalant abuse & youth. J Psychosoc Nurs Ment Health Serv. Aug 2006;44(8):15-8. [Medline].

  14. McHugh MJ. The abuse of volatile substances. Pediatr Clin North Am. Apr 1987;34(2):333-40. [Medline].

  15. Miller NS, Gold MS. Organic solvent and aerosol abuse. Am Fam Physician. Jul 1991;44(1):183-9. [Medline].

  16. Muller AA, Muller GF. Inhalant abuse. J Emerg Nurs. Oct 2006;32(5):447-8. [Medline].

  17. Muller, AA, Muller, GF. Inhalant abuse. J Emerg Nurs. 2006;32:447-8. [Medline].

  18. National Institute on Drug Abuse. Student Drug Use Attitudes and Beliefs: National Trends, 1975-1982. US Government Printing Office; 1982.

  19. US Dept of Health and Human Services. 2001 Monitoring the Future Survey. HHS News; [Full Text].

  20. Wu LT, Schlenger WE, Ringwalt CL. Use of nitrite inhalants ("poppers") among American youth. J Adolesc Health. Jul 2005;37(1):52-60. [Medline].

  21. Young SJ, Longstaffe S, Tenenbein M. Inhalant abuse and the abuse of other drugs. Am J Drug Alcohol Abuse. May 1999;25(2):371-5. [Medline].

  22. Cruz SL, Orta-Salazar G, Gauthereau MY, Millan-Perez Peña L, Salinas-Stefanón EM. Inhibition of cardiac sodium currents by toluene exposure. Br J Pharmacol. Oct 2003;140(4):653-60. [Medline].

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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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