Morning Report: 5/16/2014

Today’s Morning Report is presented by Dr. Youn!

Inhalant Abuse

Definitions: “the deliberate inhalation of vapors for the purpose of changing one’s consciousness or becoming ‘high’”  (Goldfrank’s Toxicologic Emergencies)

–       Sniffing: inhalation of a volatile substance directly from a container

–       Huffing: pouring a liquid onto fabric, placing it over mouth/nose while inhaling

–       Bagging: rebreathing from a bag in which solvent is instilled (spray paint)

–       Dusting: inhalation of compressed air cleaners

Common Inhalants:

–       glues/adhesives – toluene, benzene, tricholoethane

–       spray paint – toluene, butane, propane

–       paint thinner – toluene, methylene chloride, methanol

–       hair spray – butane, propane, fluorocarbons

–       “poppers” – amyl nitrite

–       “whippits” – NO

Pharmacology:

–       generally highly lipophilic, thus crossing blood brain barrier into CNS

–       inhalants avoid first-pass hepatic metabolism; fast onset

–       elimination via lungs; some produce toxic metabolites

–       enhance GABA and glycine receptors; inhibit NMDA receptors

–       cardiotoxicity – myocardial sensitization

Clinical Presentation:

–       History: presence of products associated with inhalant abuse, witness accounts

–       Physical Exam: Paint or stains on face, thermal or chemical burns of face/hands

–       Neurologic: CNS depression, ataxia, headache, confusion,

–       Cardiac: palpitations, tachycardia, ventricular dysrhythmias

–       Pulmonary: pneumonitis, aspiration, cyanosis (methemoglobinemia)

–       Chronic: irreversible CNS complications, RTA, rhabdo, liver disease, withdrawal

Management:

–       ABCs, IV, O2, Cardiac monitor, pulse oximetry

–       Supportive care

–       EKG for dysrhythmia, CXR for aspiration

–       Labwork? Electrolytes, COHb, co-ingestions

–       GI contamination only if co-ingestion suspected

–       Poison control

–       Evaluation for potential trauma

–       Sudden Sniffing Death Syndrome (SSDS): when the acutely intoxicated inhalant abuser is startled, causing the release of a burst of catecholamines that can trigger ventricular fibrillation

o   Ventricular dysrhythmias: shocks and beta-blockers (propranolol/esmolol); avoid sympathomimetics

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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