Inhalants Workup

  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Tarakad S Ramachandran, MBBS, FRCP(C), FACP   more...
 
Updated: Apr 16, 2012
 

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. Thiesen et al showed that toluene can be detected as urinary hippuric acid (UHA) but required correlation to blood toluene levels.[8] Chakroun et al demonstrated similar results and also detected o -Cresol and 2,5 hexandione in the urine. 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.
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Imaging Studies

Imaging studies can be useful adjuncts to the history, physical, and laboratory evaluation. Suggested studies include chest radiographs 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.
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Other Tests

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

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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.
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Contributor Information and Disclosures
Author

Edward C Jauch, MD, MS, FAHA, FACEP  Professor, Division of Emergency Medicine and Department of Neurosciences, Medical University of South Carolina

Edward C Jauch, MD, MS, FAHA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, American Medical Association, National Stroke Association, Society for Academic Emergency Medicine, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rhonda S Cadena, MD  Assistant Professor, Department of Emergency Medicine and Neurovascular Emergencies and Critical Care Fellow

Rhonda S Cadena, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jonathan S Rutchik, MD, MPH  Clinical Professor, Division of Occupational Medicine, Department of Neurology, Environmental and Occupational Medicine, University of California, San Francisco, School of Medicine

Jonathan S Rutchik, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Occupational and Environmental Medicine, and Society of Toxicology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

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: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP  Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine

Disclosure: Abbott Labs None None; Teva Marion None None; Boeringer-Ingelheim Honoraria Speaking and teaching

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Timothy Kaufman, MD and Jamie Do Kuo, MD to the development and writing of this article.

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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.
 
 
 
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