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Home , Inhalant

USE DISORDER

DANA BARTLETT, RN, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely about and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Rocky Mountain Poison Control Center.

ABSTRACT

An inhalant use disorder is diagnosed according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and includes the use of traditional categories of , such as , gases, , and . Inhalants are often used to describe volatile substances that the user inhales for a psychoactive effect. Chemicals misused as inhalants are often found in various household products that some United States jurisdictions have started to regulate. Identification and treatment of inhalant use disorder requires partnership with interdisciplinary health professionals in acute care and community settings. Inhalant use disorders require a unique approach by all members of the interdisciplinary health team to raise awareness of the risk, prevention, and available treatment when the misuse of solvents is identified.

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Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.

Continuing Education Credit Designation This educational activity is credited for 2.5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need Clinicians need to be informed about how to identify and diagnose an inhalant use disorder according to the DSM-5 criteria. To diagnose accurately, clinicians need to be able to know of the physical and psychological effects of inhalant use disorder and the available treatment for individuals when an acute intoxication condition exists.

Course Purpose To provide health professionals with information about DSM-5 criteria to diagnose an inhalant use disorder as well as the treatment and ongoing support for those affected by it.

Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members.

Disclosures Dana Bartlett, RN, BSN, MSN, MA, CSPI, Kellie Wilson, Pharm D, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test:

1. Which of the following is the definition of volatility?

a. The ability to evaporate and form a vapor b. Resistance to flow c. Decrease in temperature when compressed d. The ability to change from a gas to a liquid

2. Which of the following substances is commonly used as an inhalant?

a. b. Typewriter c. d. Water-based paint

3. Volatile solvent compounds are

a. slowly absorbed through the gut. b. rapidly absorbed through the skin. c. usually injected. d. rapidly absorbed through the .

4. The effects of commonly used inhalants may be mediated by their effect on

a. epinephrine. b. acetylcholine. c. GABA receptors. d. adenosine.

5. Which of these terms describe how inhalants are used?

a. Bagging, huffing, and sniffing b. Snorting, smoking, and gumming c. Shooting, injecting, and rocking d. Ingesting, amping, and freebasing

3 NurseCe4Less.com Introduction

Individuals who intentionally inhale chemical agents may develop an inhalant use disorder. There are many legal and commercially produced substances that can be inhaled and used as an intoxicant. These substances are highly volatile or contain high concentrations of a volatile compound. As a result, these substances or products are fast-acting and they may cause rapid, sudden harm. Fortunately, the use of inhalants appears to be declining but for those who do use them, commonly used inhalants can cause significant clinical effects. Long-term inhalant use can cause irreversible physical and psychiatric damage and inhalant use may cause sudden death. Because of these serious outcomes, it remains important to understand inhalant use disorder and the current trends in treatment.

Overview of Inhalant Use Disorder

An inhalant use disorder is defined by the American Psychiatric Association as a “... problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress.”1 Still commonly referred to as solvent use or volatile substance use, inhalant use disorder is the deliberate of the vapors from volatile organic compounds for the purpose of altering consciousness. This carries a risk for significant acute and chronic clinical symptoms in affected individuals, including sudden death. Long-term inhalant use can cause irreversible physical and psychiatric damage.

Inhalants are widely available and they can be legally purchased. Intoxication from commonly used inhalants has a rapid onset, dissipates quickly, and does not produce a marked . These attributes make inhalants an accessible option for adolescents who want to experiment with an intoxicant and they make inhalants a popular “starter” . Inhalant use is also associated with illicit drug use.

Adolescents typically use inhalants for a relatively brief period of time, with the incidence of use declining significantly as the child grows older.1

4 NurseCe4Less.com Although long-term, chronic use is quite uncommon, it has been estimated that at least 10% of American adolescents aged 13 have used an inhalant at least once.1 There is additional statistical evidence that in recent years the number of adolescents using inhalants has been declining.2

Inhalants have regularly fallen behind in popularity when compared to or marijuana. However, inhalants are dangerous substances and given the risk of commonly used inhalants to cause harmful clinical effects, including sudden death, inhalant use disorder is considered a serious public health problem.

Products and Solvents Commonly Used

Many legal and commercially produced substances can be used as inhalants, however before discussing these substances, it is important to define important terminology relative to inhalant use.

TABLE 1: DEFINITIONS OF INHALANT USE

Solvent A solvent is defined as a substance that is capable of dissolving. Solvents are valued for this capability and are often used as a carrier vehicle for other chemicals or compounds.

Examples include: simple petroleum distillates are often used as a carrier vehicle in household pesticides and alcohol is used as a solvent/carrier vehicle in products such as mouthwashes and solid . is one of the most common solvents and is often found in products such as glue that are used for inhalant use.

Volatile Volatility is defined as the ability to evaporate and form a vapor.

Vapor A vapor is defined as the gaseous form of a liquid.

Hydrocarbon A hydrocarbon is an that contains carbon and hydrogen only. Hydrocarbons are derived from petroleum (oil), they can be gases or liquids, and hydrocarbon-based products are perhaps the most common solvent used.

Hydrocarbons are in use everywhere; , lighter fluid, , and paint thinner are hydrocarbons.

5 NurseCe4Less.com Some examples of the more common products used as inhalants are listed below in Table 2.3-6 Many of the products listed in Table 2 differ in their ingredients and some are quite similar or almost identical to each other. Regardless of the differences or similarities, each one contains a solvent or is a compound that can be used as a solvent.

TABLE 2: PRODUCTS USED AS INHALANTS

Air fresheners Cleaning products Computer keyboard cleaners Fluorinated hydrocarbons, i.e., Freon Gasoline Glue Hair spray Lighter fluid Nail polish remover Pain stripper Paint thinner Simple asphyxiant gases, i.e., , Spray paints Typewriter correction fluid Whipped cream dispensers

Solvents are volatile and they can easily evaporate to form a vapor. In addition, many solvents are hydrocarbons. Substances that are used as solvents rarely involve a single compound. In addition, some of the products in Table 2 may not contain a hydrocarbon, may be a mixture of many hydrocarbons, may be a mixture of hydrocarbons and non-hydrocarbon compounds, and may not be used as solvents.3-6 For example, gasoline and the simple asphyxiants are hydrocarbons; they are volatile and are often used, but they are not solvents.

Glues themselves are not solvents, but typically contain hydrocarbons such as and toluene that are used as solvents. They often contain , a which is not a hydrocarbon but that forms a vapor that can cause intoxication.3-6 6 NurseCe4Less.com This complexity in nomenclature and in the nature of the products that may be inhaled can make understanding solvent use difficult but if the definitions in Table 1 and the definition of solvent use are kept in mind, understanding the problem of inhalant use disorder becomes more clear. An example is typewriter correction fluid, which contains a hydrocarbon, such as trichloroethane. The hydrocarbon acts as a solvent for the other ingredients that make correction fluid. The chemical properties of hydrocarbons allow them to easily form a vapor. It is the vapor from the hydrocarbon that is inhaled and produces intoxication.3-6

TABLE 3: COMMONLY USED SOLVENTS/PRODUCTS3-6

● Acetone: Glues, nail polish removers, paint removers ● Amyl : Vasodilator, cyanide antidote ● Butane: Fuels for lighters, stoves, etc. ● Fluorocarbons: Propellants in many cans ● Hexane: Glues ● Hydrocarbons: Gasoline, lighter fluid, paint thinner ● : Adhesives, paints ● : Automotive products ● Methylene chloride: Paint strippers ● spirits: Paints, paint thinner ● Naphtha: Glues, paint thinner ● Nitrous oxide: Propellant in some whipped cream canisters ● Toluene: Glues, lacquer thinner ● Trichloroethane: Typewriter correction fluid ● : Glues, paint strippers

Pharmacology

Although Table 2 is a list of very different products, they all are (or contain compounds that have similar properties) attractive to individuals who seek them for the purposes of inhalant use. These desired properties by those seeking the effects of inhalants include rapid absorption, high lipid solubility, and rapid metabolism.6,7

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Rapid Absorption

The substances or products used for inhalant use are volatile compounds, or they have a high concentration of a volatile compound. These volatile compounds are very rapidly absorbed through the lungs and they move quickly and efficiently into the pulmonary circulation.6.7

High Lipid Solubility

The volatile compounds that are used as inhalants are very lipid soluble. This property (in combination with their rapid absorption through the lungs and into the pulmonary circulation) allows them to readily reach organs and tissues that have high lipid content, i.e., the brain, kidneys, and the . In particular, the volatile inhalants easily cross the blood-brain barrier and enter the and they do so almost immediately.6,7

Rapid Metabolism

The volatile inhalants are quickly metabolized and excreted. These specifics about the volatile compounds that are used as inhalants clearly illustrate why they are so attractive to people who want to get high. No special equipment or techniques are needed to use them, and intoxication begins within seconds of use and is relatively brief.6,7 The inhalant use disorder offers a cheap simple high with a relatively low commitment and an immediate and dramatic change in consciousness.

These characteristics explain why these volatile compounds produce intoxication so quickly and easily, but it is not known exactly how they do so. However, the similarities between the clinical effects of the used volatile compounds closely resemble the clinical effects of , , and , and it is possible that they work in the same way. Barbiturates, benzodiazepines, and ethanol all have receptors that are in close proximity to gamma-aminobutyric acid (GABA) receptors.6-8 These produce central nervous system effects by increasing the

8 NurseCe4Less.com activity of GABA receptors; and, while the mechanism of action is not known, there is evidence that suggests that the clinical effects of volatile compounds are mediated by GABA receptors as well.6-8

It has also been speculated that the volatile compounds identified in solvent use may decrease the activity of N-methyl-D-aspartate, NMDA, which is part of the glutamate excitatory neurotransmitter system. Inhalants may also affect dopamine, glycine, , and serotonin receptors.6-8 Gamma- aminobutyric acid binds to specific post-synaptic cell receptors and hyperpolarizes cell membranes by increasing the duration and frequency of the opening of chloride ion channels. Because of the hyperpolarization, the affected cells are less able to depolarize in response to a stimulus. N-methyl- D-aspartate (NMDA) is an amino acid derivative, which is not naturally occurring.6-8 NMDA refers to a specific glutamate receptor that is stimulated by this compound and the term NMDA is used to identify that type of glutamate receptor.6-8

Another substance that is popular for inhalant use is and this compound has a well defined and understood mechanism of action. Amyl nitrite relaxes smooth muscle and acts as a vasodilator, and it also promotes the formation of methemoglobin (discussed later on). Amyl nitrite is supplied in small glass capsules covered with gauze. The capsule is crushed, held directly underneath the nose and the vapors inhaled. Amyl nitrite was once popular as an emergency treatment for angina, and it still has a limited role as a cyanide antidote.6-8

Etiology of Solvent Use Disorder

Solvent use is not limited to any specific geographical area. It is generally more popular among preteens and teens and in lower socio- economic groups.4 Males are more likely to try solvents but whether solvents are used by males or females, chronic, long-term inhalant use is the exception; most people who use solvents experience this as a phase and stop completely by their late 20s.9 Solvent use is more common in pre-teens and younger teens and many will go on to try illicit drugs. It may be that as the

9 NurseCe4Less.com user gets older and becomes more affluent and mobile, more expensive and difficult to obtain drugs such as cocaine and marijuana became popular.9

Selling or distributing to minors any products that contain commonly used solvents, i.e., spray paint, is illegal almost everywhere in the United States.6 The laws regarding the use of these products for the purposes of intoxication, or being intoxicated from a solvent vary from state to state. Driving under the influence (DUI) laws can be applied to solvent use in certain states, as well. In many states the law prohibits the sale, transfer or offer to sell to a minor any vapor containing substance that contains a toxic ingredient. In some states these laws are quite specific and in others they are not.9

Solvents are usually used by one of three methods. Sniffing is simply inhaling the product directly from the container. Huffing is saturating a piece of cloth or paper with the product, placing this over the mouth and nose, and inhaling. Bagging involves pouring or spraying the product into a paper or plastic bag and then periodically inhaling the vapors from the bag, closing the bag between , and then opening again to inhale.10 People who use solvents often inhale very large concentrations of vapor. Glue sniffers may inhale a concentration of vapor that is hundreds of times higher than what would be allowed by the Occupational Safety and Health Administration (OSHA) in a workplace.10

Diagnosis of Inhalant Use Disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition uses specific criteria for diagnosing an inhalant use disorder. The individual in question has a problematic pattern of use of a hydrocarbon-based inhalant substance that leads to clinically significant impairment or distress, and is accompanied by at least two of the following in a 12-month period.1

1. The inhalant is often used in larger amounts or over a longer period than the user intended. 2. The user has a persistent desire or makes unsuccessful efforts to cut down or control his or her use.

10 NurseCe4Less.com 3. Significant time is expended obtaining the inhalant, using it, or recovering from intoxication. 4. He or she has a craving or strong or urge to use the inhalant substance. 5. Inhalant use is the cause of failure to meet important obligations at home, school, or work. 6. Inhalant use continues despite persistent or recurrent social or interpersonal problems caused or exacerbated by its effects. 7. Occupational, social, or recreational activities are stopped or reduced because of inhalant use. 8. The inhalant is repeatedly used in physically dangerous situations. 9. Inhalant use continues despite knowing that persistent physical or psychological problems that are likely to have been caused or exacerbated by the substance. 10. Tolerance is present, this being defined as either: a. Needing greater amounts to become intoxicated, or b. A decreased level of intoxication from the same amount of inhalant.

If possible the specific inhalant should be identified and it should be determined if the patient is in early or sustained remission.

Acute inhalant intoxication is defined in the DSM-5 as: “Inhalant intoxication is an inhalant-related, clinically significant mental disorder that develops during, or immediately after, intended or unintended inhalation of a volatile hydrocarbon substance.”1 Acute intoxication from an inhalant is diagnosed using the following criteria.1

1. The patient has recent intended or unintended short-term, high-dose exposure to inhalant substances, including volatile hydrocarbons such as toluene or gasoline. 2. Clinically significant behavioral or psychological changes exist that are maladaptive and problematic such as belligerence, assaultive behavior, apathy, impaired judgment that developed during, or shortly after, exposure to inhalants.

11 NurseCe4Less.com 3. The patient has two or more of the following signs or symptoms that occur during or shortly after use of an inhalant. a) . b) Nystagmus. c) Incoordination. d) Slurred speech. e) Unsteady gait. f) Lethargy. g) Depressed reflexes. h) Psychomotor retardation. i) Tremor. j) Generalized muscle weakness. k) Blurred vision or diplopia.

Other inhalant-induced disorders described in the DSM-5 include inhalant-induced psychotic disorder, inhalant-induced depressive disorder, inhalant-induced disorder, inhalant-induced major or mild neurocognitive disorder, and inhalant intoxication delirium.1

Primary Acute Clinical Effects

The primary acute clinical effects of inhalant intoxication are neurological and cardiac. However, other organ systems can be affected as well and every effort should be made to identify the product as there are specific problems associated with some of the less commonly used inhalants.

Neurological

The most common neurological effect of solvent inhalation is central nervous system . This can range from mild drowsiness to , and it is usually preceded by a mild level of excitation and .3 Patients can also develop ataxia, confusion, diplopia, dizziness, , headache, euphoria, seizures, slurred speech, tremor, and weakness.3-6

12 NurseCe4Less.com The intensity of the central nervous system effects can be mild and they can be profound. The duration of the neurological effects - the high - is typically an hour or two, but depending on the pattern of use it may be more or less.3-6

Cardiovascular

Tachycardia is common. Conversely, reflex bradycardia caused by vagal stimulation is possible, and atrioventricular block and other conduction abnormalities, cardiomyopathy, and have been reported.10-13 Deadly ventricular and sudden death caused by solvent use are well described in the medical literature but given the enormous number of incidents of huffing, sniffing, and bagging these effects are uncommon.13,14

The mechanism by which sudden death from inhalant use occurs is not completely understood, but it may involve sensitization of the myocardium to catecholamines, QT prolongation, increased level of catecholamines, or inhibition of the potassium and/or sodium in channels of the myocardium.14,15 If the solvent user experiences a catecholamine surge, for example, in a situation of running to avoid police custody or arrest, the sudden and intense increase in circulating levels of epinephrine and norepinephrine will stimulate the vulnerable myocardium and produce an .

On the other hand, vagal stimulation and bradycardia that has been reported in solvent use may be due to cold stimulation of the larynx and throat. These situations have been well documented and are called sudden sniffing death.16,17 Sudden sniffing death can happen to a first-time solvent user or to someone who is chronically inhaling solvents, and although it most often happens very soon after inhalation of a solvent, ventricular fibrillation can occur hours after an exposure.

13 NurseCe4Less.com Pulmonary

Many of the inhaled solvents act as irritants so cough, dyspnea, and wheezing are common pulmonary effects.18-21 Because the volatile solvents are simple asphyxiants and centrally acting respiratory , is one of the primary acute effects of solvent use. Freezing injuries from inhalation of fluorinated hydrocarbon propellants and acute upper airway obstruction after volatile substance inhalation have been reported. Airway obstruction caused by angioedema has been reported, as well.18-21 Aspiration of a liquid hydrocarbon can cause chemical pneumonitis, and people who indulge in long sessions of bagging may develop hypercapnia.

Metabolic and Hematologic

Except for toluene exposure metabolic effects are not common after use of the common inhalants, but there are some products that can produce metabolic derangements or have the capability of doing so. Paint strippers can contain methylene chloride. Methylene chloride is converted in vivo to carbon monoxide and carbon monoxide has been reported after accidental exposure to or improper use of paint strippers.22 Some automotive products contain ethylene glycol and/or methanol, toxic that can cause metabolic acidosis.23,24

The nitrites, amyl nitrite, , and , act as oxidative stressors and convert hemoglobin to methemoglobin. Methemoglobin is hemoglobin that has lost an electron from its iron atom. Methemoglobin is normally produced as the body encounters oxidative stressors, but reducing mechanisms normally maintain the methemoglobin level at 1-3%. The iron molecule in methemoglobin is in the ferrous Fe2+ state instead of its normal ferric Fe3+ state and ferrous iron cannot combine with oxygen. Symptomatic has been reported after nitrite use.25 Acute toluene intoxication can cause hypokalemic paralysis and a normal anion gap metabolic acidosis.26-28

14 NurseCe4Less.com Gastrointestinal

Abdominal pain, diarrhea, nausea and vomiting are possible as a result of inhalant use. Hydrocarbons are well known to be very irritating to the gut.

Dermal

The gases that are in aerosol cans are compressed and under high pressure. When they are released and they rapidly expand, the gases are cooled and can cause cold thermal injuries to the skin and the respiratory tract, in some cases significant enough to require endotracheal intubation.29 Many of the solvents and hydrocarbons act as defatting agents (they “dissolve” the normal surface oils on the skin) and if there is dermal contact the skin can become dry and cracked. Prolonged skin contact can cause first degree and more serious .

Fatalities

It is not possible to form an accurate estimate of the number of fatalities caused by an inhalant use disorder, but deaths caused by the use of these substances appear to be very unusual. The American Association of Poison Control Centers (AAPCC) publishes a yearly reporting of overdose and accidental called into poison control centers, and the number of deaths attributed to or caused by inhalants is very small.30 The mechanisms by which inhalants can kill are listed in Table 4.31-33

15 NurseCe4Less.com TABLE 4: SOLVENT USE AND DEATH

Aspiration, Allergic reaction Central nervous system depression Ventricular arrhythmias Hypoxia Respiratory depression Trauma Vagal inhibition Methemoglobinemia

Intoxication from a volatile solvent may last for 15-30 minutes or for several hours, and the recovery is rapid. Chronic users develop a tolerance and a withdrawal syndrome has been described.34-36

Assessment for Inhalant Intoxication

Unless the use of an inhalant is witnessed, obvious signs of use (i.e., paint residue around the mouth or nose), chemical odor on the patient’s breath, or if the patient admits to using, determining the presence of acute inhalant intoxication depends on nonspecific signs or symptoms. Table 5 lists some common physical and behavioral signs of inhalant use. Some of the commonly used substances can be detected in blood or urine by laboratory testing but not in a timely manner. Primary care providers or other healthcare professionals that screen patients for the presence of inhalant use can utilize the Volatile Solvent Screening Inventory (VSSI) or the Comprehensive Solvent Assessment Interview (CSAI).34

16 NurseCe4Less.com TABLE 5: SIGNS OF INHALANT USE

Behavior changes (apathy, depression, hostility, paranoia, social withdrawal) Conjunctivitis Chronic fatigue Confusion Decreased appetite Drowsiness Epistaxis or burns in/around the mouth or nose Poor hygiene and grooming Weight loss Wheezing

Chronic Clinical Effects

If solvent use is sporadic and the duration of use is brief, there are no sequelae. However, long-term use of a solvent can cause multi-organ system damage. Some of the organ damage can be reversible, but the cardiac and neurological changes may become permanent. The nervous system is especially at risk. As mentioned previously, inhaled solvents are highly lipophilic and because of that they accumulate in (75% lipid) and in neuronal membranes (up to 45% lipids).36,37 Cardiovascular

Myocardial infarction, cardiomyopathy with depressed ejection fraction, congestive , and chronic myocardial inflammation and fibrosis have been reported after chronic inhalant use.36,37

Neurological

Chronic solvent inhalation can cause serious, significant and irreversible neurological damage, cognitive, motor, and visual impairment. Cerebellar damage, cortical atrophy, dementia, peripheral neuropathy, and optic nerve damage have all been reported as consequences of chronic solvent use, and there is a wide range of clinical effects that these injuries produce, i.e., ataxia,

17 NurseCe4Less.com depression, headache, intellectual impairment, memory loss, mood changes, sensory disorders, spasticity, tremor, among many other symptoms. It is not clear how long solvent use must continue before neurological damage becomes permanent, and there is no clear dose-response relationship.36,37

Chronic solvent use is also associated with increased risk for and suicidal ideation, psychosis, attention deficit hyperactivity disorder, concurrent use of alcohol, , and illicit drugs, anxiety, depression, and other mental health disorders.36,37

Pulmonary

Long-term solvent use has been associated with Goodpasture’s syndrome, panacinar emphysema, decreased vital capacity, decreased exercise tolerance, coughing, recurrent epistaxis, chronic rhinitis, and other pulmonary abnormalities.36,37

Renal

Toluene is often used as a solvent in glue. Chronic toluene inhalation is a well-known cause of renal tubular acidosis.36,37

Hepatic

Exposure to , toluene, and has been associated with liver damage. Fortunately, the risk of liver damage from exposure to these substances - carbon tetrachloride in particular - is well recognized and their availability in over-the-counter products is much less than previously. Exposure to toluene has been reported to cause hepatorenal syndrome.36,37

Inhalant Use Disorder Clinical Care

Individuals with inhalant use disorder may seek help for acute medical problems or chronic problems.38-40 The care will differ somewhat for each

18 NurseCe4Less.com situation, but in either case a careful history should be taken. The clinician should be sure to ask the individual the following during a history and physical.

● When was the substance last inhaled. ● If solvent use was experimental or chronic. ● How the inhalant was used; i.e., by bagging, huffing, or inhaling. ● What is being inhaled, i.e., liquid, such as paint thinner) or aerosol, such as computer keyboard cleaner. ● Is there polysubstance use, such as illicit drug or alcohol use combined with inhalant use.

Most importantly, it should be determined what the patient has been using and what it contains. It is not enough to simply know what the patient has been inhaling, for example, an automotive brake cleaner; a list of the ingredients that the patient has been inhaling must be obtained. Although many of the clinical effects produced by solvent inhalation are common to all of the typically used products, the patient may be inhaling something that can cause a distinct pathology; for example, carbon monoxide poisoning from paint strippers that contain methylene chloride, glues that contain toluene can cause renal damage.38-40

If the patient cannot inform the clinician what was being inhaled (doesn’t remember, is incapacitated, etc.), someone not directly involved in patient care should try to obtain this information. There are four ways to get a list of ingredients for a commercially manufactured product. These are listed here from the simplest to the most difficult.40

1. Call the local poison control center. Poison control centers all have a database that contains detailed information about millions of commercial products, and a local center may be able to quickly provide information of what is in the product that a person has been using.

Many poison control centers still maintain a local number, but all poison control centers use the national number, and this number will connect callers to the closest poison control center: 1-800-222-1222.

19 NurseCe4Less.com 2. Look for the material safety data sheet (MSDS) online. This can be done by going to the manufacturer’s website (if the manufacturer of the product is known) and checking to see if they have the MSDS, or by doing a simple online search using any search engine; i.e., type in “Amazing Automotive Heavy Duty Brake Cleaner, MSDS”.

3. Check with Chemtrec. Chemtrec is a free service that provides emergency assistance to HAZMAT teams, first responders, etc., dealing with a hazardous materials incident such as a chemical spill. In addition, Chemtrec also has a database of manufacturers and access to the MSDS of their products.

Chemtrec is available 24 hours at 1-800-424-9300.

4. Call the manufacturer and have the MSDS emailed or faxed. This last option is by far the slowest and least reliable. The company may be closed (if the call is placed on the weekend or at night) or it may take someone in the company a long time to find the information. Locating current contact information can be challenging, as well.

Acute Care of Toxic Exposure

When an individual arrives to an acute care setting due to a serious outcome related to inhaling a substance, care begins with an assessment of the patient’s airway, breathing, and circulation, and the individual should be checked for any signs of a traumatic injury. As this assessment is being done, any contaminated clothing should be removed and health team responders should decontaminate the skin if needed.4,41

A close examination of the oral cavity and the surrounding area should be done for evidence of obstruction or thermal injury (due to edema or cold thermal injury), and the lungs carefully auscultated and the oxygen saturation checked using pulse oximetry. The clinician should be looking for signs of aspiration and/or hypoxia.4,41

20 NurseCe4Less.com If there are abnormalities in the assessment of the airway and breathing, or if the patient is complaining of dyspnea, the following should be obtained: a chest x-ray, an arterial blood gas, and measurement of serum carbon monoxide and methemoglobin levels.4,41 A 12-lead ECG should be obtained and the patient should be placed on continuous cardiac monitoring. Serum electrolytes, a complete blood count, liver transaminases, blood urea (BUN) level and a creatinine level should be obtained. The volatile solvents and their metabolites are not detected in urine drug screens and although they can be detected in the blood by using chromatography, this type of testing cannot be done stat or immediately; the results would take several days to be available.4,41

There are no specific treatments for acute solvent intoxication. Treatment is essentially symptomatic and supportive.4,41 If the patient is having respiratory distress, the following approach should be followed.

Respiratory Distress

If there is evidence of airway constriction, it should be determined where the problem is; it could be in the upper airway structures (i.e., thermal damage from an inhalant) or it could be in the lower airway structures (i.e., response to the irritating nature of a solvent or from an aspiration). Supplemental oxygen should be administered and if the airway constriction is in the lower airway structures, the clinician should carefully consider the benefits and risks of an inhaled such as albuterol.

If the patient is having respiratory distress and has an abnormal chest X-ray, aspiration and chemical pneumonitis are likely. The treatment includes supplemental oxygen and consultation with a poison control center or a pulmonologist about the use of antibiotics and systemic corticosteroids; these are not typically needed or useful but may be in certain circumstances. In a situation of a high carbon monoxide level, supplemental oxygen and time should be sufficient treatment.

21 NurseCe4Less.com If a product that causes methemoglobinemia has been inhaled and the patient becomes symptomatic, such as the patient develops respiratory distress, or has a methemoglobin level that is >20%, immediate treatment is necessary.42 Clinicians should be aware that a blood gas analysis may provide an unreliable oxygen saturation level in patients with methemoglobinemia.42 This is because arterial oxygen partial pressure will measure normal in patients with methemoglobinemia.42

There are two treatments that are most often used in patients with methemoglobinemia. They are methylene blue and ascorbic acid (vitamin C).42 In an emergency care setting, a single dose of methylene blue “rapidly reduces toxic levels of methemoglobin to non-toxic levels (<10 percent) within 10 to 60 minutes.”42 Ascorbic acid, on the other hand, requires multiple doses and can take 24 hours or more to restore non-toxic levels.42 Ascorbic acid is not recommended in acute, emergency settings.42

If the arterial blood gas reveals a metabolic acidosis, the patient may have inhaled a product that contains ethylene glycol or methanol but it should be noted that toluene exposure is also possible.43 Blood samples should be sent for measurement of ethylene glycol and methanol, and for close monitoring of acid-base status and renal function.43 The patient should also be assessed for visual deficits. Intravenous hydration should be started and if exposure to ethylene glycol or methanol is confirmed or strongly suspected, the use of fomepizole or hemodialysis should be considered.43 There should be consultation with the local poison control center for advice.

Cardiovascular Abnormalities

A 12-lead ECG should be done for every patient who is using inhalants and measurement of serum calcium, magnesium, and potassium should be done, as well.4 If the patient is having an arrhythmia, it should be treated with established protocols; consultation with a poison control center toxicologist should be obtained, as well.

22 NurseCe4Less.com Sympathomimetic drugs such as epinephrine, isoproterenol, or norepinephrine should not be used to treat ventricular fibrillation (VF), and catecholamines and drugs that are adrenergic should only be used after a careful risk-benefit analysis and after consultation with a toxicologist or a cardiologist. Hypotension can be treated with fluids.4

Chronic Solvent User

Chronic solvent users should be evaluated for neurological, cardiovascular, renal, hepatic, and hematologic problems, so the appropriate testing should be ordered and consultation made.4 There is no specific treatment for health problems caused by chronic solvent use; patients should be treated with symptomatic and supportive care and the appropriate consultations. Neurological and cardiac damage is likely to be permanent whereas damage to other organs will usually resolve and repair over time.4

Patients who have an inhalant use disorder will need psychological support and counseling. Unfortunately there is a dearth of good research on the medical, pharmacological, and psychological interventions for this problem and no clear conclusions as to which approach is best.

Case Study: Inhalant Use and Toxic Exposure

The following case study was obtained through a PubMed search and the authors reported on a 24 year old man who was hospitalized for a painful rash.44

The patient’s personal health history showed no significant medical problems and no prior history of skin disease. The patient reported no known allergies, and there were no family members with a history of skin disease. He emphatically denied drug and alcohol use. He was employed by a car factory and worked on an assembly line, and he denied exposure to chemicals.

23 NurseCe4Less.com A history of the patient’s present health concern was obtained upon admission to the hospital emergency department. The authors reported he reported a “progressive, tender, blistering rash developed, involving the left side of his upper chest, left arm and left hand” one week prior to admission.44 He denied common causes such as use, preceding infections, new or different topical products, travel history, insect bites, new or multiple sexual partners, and close contacts with similar eruptions.

On physical assessment, the patient’s lips, oral mucosa, and tongue reportedly had corresponding erosions and he complained of painful gums. There was “blanching, erythematous to violaceous patches and plaques with sharply defined borders on the left side of the upper chest, shoulder, and arm. Tender, tense bullae were found on the left shoulder and left lateral arm. Thick yellow-brown plaques with yellow crust were noted on his right thumb. Postinflammatory hyperpigmentation was also noted on the proximal right leg and inguinal fold. Superficial erosions on his tongue and oral commissures with hemorrhagic crust were also noted, and the nasal tip contained a crusted plaque.”44 A similar rash on his right leg and groin had been noticed one month before admission, which had resolved spontaneously with residual dark areas to the skin. The leg rash was reportedly stable.

Initial treatment while in the emergency department included administration of intravenous fluids and broad-spectrum antibiotics for nausea and vomiting, and for suspected cellulitis. Initial testing included chest and abdominal radiographs and electrocardiogram results that were normal. Laboratory testing included a complete blood count that showed elevated a leukocytosis (14.1) with neutrophilia (84%). Troponin levels were obtained and elevated to 1.180. A urine drug screen result was negative.44

The authors reported their initial differential diagnosis covered a range of possible causes, which included “vasculitides and vasculopathies (including levamisole vasculopathy), infectious etiologies (gonococcal, septic thrombosis), irritant or allergic dermatitis, fixed drug eruption, and chemical ingestion. We also considered erythema multiforme with associated viral etiology, given the gastrointestinal symptoms.”44 Further, they obtained a

24 NurseCe4Less.com lesional shave biopsy from the left upper lateral arm for hematoxylin-eosin, which showed epidermal necrosis with subepidermal bulla formation. They also reported that the patient’s hepatitis B serology and hepatitis C polymerase chain reaction, rapid plasma reagin, rheumatoid factor, antineutrophil cytoplasmic antibodies, cryoglobulins, D-dimer, wound, and blood cultures were all normal.44

The patient eventually admitted after several days in the hospital that he used inhalants, and that prior to admission, he had been huffing computer dust cleaning products (containing the hydrofluorocarbon, 1,1 difluoroethane) known to cause cryogenic burns. He continued to receive dermatological care, was medically stabilized, and referred to mental health and substance use counseling. He eventually discharged home in stable condition, however did not follow up after discharge.44

Discussion

The intentional inhalation of toxic, industrial-use inhalants for temporary euphoria, has reportedly become increasingly common, especially among youth. Substances are inhaled directly from the container or from a bag or cloth to which the inhalant has been placed, and aerosol sprays (a pressurized liquid form) are “usually a hydrocarbon such as propane, butane, or isobutene.”44 These inhalants can lead to a very brief intoxication (lasting seconds), and it is common for inhalant use to develop into an inhalant use disorder.

Symptoms of acute intoxication include “dizziness, loss of coordination, euphoria, and sometimes loss of consciousness.”44 Chemical or thermal burns may be visible. The authors noted that studies of aerosol spraying an object from 1 cm away brings its temperature down from room temperature to 0°C in 5 seconds and to –15°C in as little as 20 seconds. In some studies, aerosol spraying from 5 cm decreased temperature to 0°C in 3 seconds, which reveals how quickly an may lead to frostbite.

25 NurseCe4Less.com Inhaled substances are sold legally for industrial purposes and generally at low cost. This makes the substance accessible to people of all ages. The authors noted: “When the trigger is pulled, gas exits the nozzle at temperatures below freezing and immediately vaporizes. However, if the can is shaken or turned upside down, liquid will be released, freezing any tissue that may be exposed to it.”44 They reported on cases of individuals who inhaled substances directly to the mouth to the point of loss of consciousness while the container remained open with contents fully expressed leading to severe damaging outcomes. Patients were reported to sustain severe oral, pulmonary, gastric mucosa and skin damage that was in contact with the expressed gas/liquid. In this case, the authors noted that the spray can would have been held to the patient’s lips with the use of his right hand and index finger depressing the plastic trigger and thumb in contact with the cool, metallic can. The cool inhalant material in contact with the lips, tongue, and oral mucosa would have continued to express its contents in contact with skin surfaces after he lost consciousness, potentially dropping the canister and losing control over sprayed chemicals.

The authors recommended that health clinicians need to include inhalant use in their differential diagnosis due to its wide use and the fact that common chemicals inhaled are not detectable through routine urine or blood testing.44 As in this case, patients are often reluctant to self report a problem of inhalant use. Patients with suspected inhalant use may be asked to complete a Volatile Solvent Screening Inventory to help rule out types of inhalant use. In cases involving cryogenic burns, especially in youth or young adults, inhalant use disorder should be suspected, especially periorofacial or unilateral hand burns commonly seen with inhalant use.

Summary

Inhalant use disorder is defined as the problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress. Also known as solvent use or volatile substance use, the use of solvent-based inhalants can cause serious and irreversible complications and death. Inhalant use disorder is a relatively common

26 NurseCe4Less.com phenomenon in pre-teen and adolescent populations, and its popularity can be explained in part because the inhalants are cheap and legal and the high is relatively brief.

The effects of inhalant intoxication typically last for one to two hours and central nervous system depression and tachycardia are the most commonly seen clinical signs. More serious effects such as airway compromise or damage, hypoxia, respiratory depression, metabolic acidosis, methemoglobinemia, carbon monoxide poisoning, renal tubular acidosis, and deadly cardiac arrhythmias are possible, as well. Chronic use of inhalants can cause irreversible cognitive effects and neurological damage, cardiomyopathy, hepatic and renal damage, and myocardial damage. The treatment of acute inhalant intoxication and inhalant use disorder is essentially symptomatic and supportive.

27 NurseCe4Less.com Self-Assessment of Knowledge Post-Test:

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.

1. Which of the following is the definition of volatile?

a. The ability to evaporate and form a vapor b. Resistance to flow c. Decrease in temperature when compressed d. The ability to change from a gas to a liquid

2. Which of the following substances is commonly used as an inhalant?

a. Cocaine b. Typewriter correction fluid c. Methamphetamine d. Water-based paint

3. Volatile solvent compounds are

a. slowly absorbed through the gut. b. rapidly absorbed through the skin. c. usually injected. d. rapidly absorbed through the lungs.

4. The effects of commonly used inhalants may be mediated by their effect on

a. epinephrine. b. acetylcholine. c. GABA receptors. d. adenosine.

5. Which of these terms describe how inhalants are used?

a. Bagging, huffing, and sniffing b. Snorting, smoking, and gumming c. Shooting, injecting, and rocking d. Ingesting, amping, and freebasing

28 NurseCe4Less.com 6. Which of the following is a common effect of acute inhalant intoxication?

a. Myocardial infarction b. Drowsiness c. Congestive heart failure d. Liver damage

7. Common pulmonary effects of acute inhalant intoxication can include

a. pulmonary edema. b. . c. hypoxia. d. pulmonary embolism.

8. Common pulmonary effects of acute inhalant intoxication can include

a. left to right shunt. b. atelectasis. c. pneumothorax. d. respiratory depression.

9. Pulmonary effects of acute inhalant intoxication can include

a. airway damage. b. tracheoesophageal fistula. c. pulmonary fibrosis. d. viral infections.

10. True or False: Inhalant use can cause cold thermal burns.

a. True b. False

11. Toluene intoxication can cause

a. carbon monoxide poisoning and methemoglobinemia. b. renal tubular acidosis and hypokalemic paralysis. c. angioedema and airway damage. d. myocardial infarction and bacterial pneumonia.

29 NurseCe4Less.com 12. Sudden death from inhalant use is thought to be caused by

a. a pulmonary embolism. b. electrolyte disturbances. c. ventricular arrhythmias. d. cardiogenic shock.

13. Inhalants that contain ethylene glycol or methanol can cause

a. methemoglobinemia. b. carbon monoxide poisoning. c. hypokalemic paralysis. d. metabolic acidosis.

14. Inhalants that contain methylene chloride can cause

a. carbon monoxide poisoning. b. methemoglobinemia. c. renal tubular acidosis. d. hyperkalemia and hyponatremia.

15. Nitrite-based inhalants can cause

a. carbon monoxide poisoning. b. methemoglobinemia. c. anemia. d. leukopenia.

16. True or False: Sympathomimetic drugs should not be used to treat ventricular arrhythmias caused by inhalants.

a. True b. False

17. Sudden death caused by inhalant use is

a. very common. b. common only in adolescent users. c. is very uncommon. d. common because of the rapid onset of inhalants.

30 NurseCe4Less.com 18. True or False: Irreversible cognitive or neurological damage can occur after chronic inhalant use.

a. True b. False

19. Symptomatic methemoglobinemia is treated primarily by using

a. diuretics. b. methylene blue. c. hyperbaric oxygen. d. fomepizole.

20. The primary treatment for acute inhalant intoxication is

a. IV fluids and benzodiazepines. b. methylene blue and oxygen. c. airway control and corticosteroids. d. symptomatic and supportive care.

31 NurseCe4Less.com CORRECT ANSWERS:

1. Which of the following is the definition of volatility? a. The ability to evaporate and form a vapor

“Volatility is defined as the ability to evaporate and form a vapor.”

2. Which of the following substanceS is commonly used as an inhalant? b. Typewriter correction fluid

“TABLE 2: PRODUCTS USED AS INHALANTS … Typewriter correction fluid.”

3. Volatile solvent compounds are d. rapidly absorbed through the lungs.

“The substances or products used for inhalant use are volatile compounds, or they have a high concentration of a volatile compound. These volatile compounds are very rapidly absorbed through the lungs and they move quickly and efficiently into the pulmonary circulation.”

4. The effects of commonly used inhalants may be mediated by their effect on c. GABA receptors.

“These drugs produce central nervous system depressant effects by increasing the activity of GABA receptors; and, while the mechanism of action is not known, there is evidence that suggests that the clinical effects of volatile compounds are mediated by GABA receptors as well.”

5. Which of these terms describe how inhalants are used? a. Bagging, huffing, and sniffing

“Solvents are usually used by one of three methods. Sniffing is simply inhaling the product directly from the container. Huffing is saturating a piece of cloth or paper with the product, placing this over the mouth and nose, and inhaling. Bagging involves pouring or spraying the product into a paper or plastic bag and then periodically inhaling the vapors from the bag, closing the bag between inhalations, and then opening again to inhale.”

32 NurseCe4Less.com 6. Which of the following is a common effect of acute inhalant intoxication? b. Drowsiness

“The primary acute clinical effects of inhalant intoxication are neurological and cardiac. However, other organ systems can be affected as well and every effort should be made to identify the product as there are specific problems associated with some of the less commonly used inhalants. Neurological: The most common neurological effect of solvent inhalation is central nervous system depression. This can range from mild drowsiness to coma, and it is usually preceded by a mild level of excitation and euphoria.”

7. Common pulmonary effects of acute inhalant intoxication can include c. hypoxia.

“Pulmonary: Many of the inhaled solvents act as irritants so cough, dyspnea, and wheezing are common pulmonary effects. Because the volatile solvents are simple asphyxiants and centrally acting respiratory depressants, hypoxia is one of the primary acute effects of solvent use.”

8. Common pulmonary effects of acute inhalant intoxication can include d. respiratory depression.

“The effects of inhalant intoxication typically last for one to two hours and central nervous system depression and tachycardia are the most commonly seen clinical signs. More serious effects such as airway compromise or damage, hypoxia, respiratory depression, metabolic acidosis, methemoglobinemia, carbon monoxide poisoning, renal tubular acidosis, and deadly cardiac arrhythmias are possible, as well.”

33 NurseCe4Less.com 9. Pulmonary effects of acute inhalant intoxication can include a. airway damage.

“The effects of inhalant intoxication typically last for one to two hours and central nervous system depression and tachycardia are the most commonly seen clinical signs. More serious effects such as airway compromise or damage, hypoxia, respiratory depression, metabolic acidosis, methemoglobinemia, carbon monoxide poisoning, renal tubular acidosis, and deadly cardiac arrhythmias are possible, as well.”

10. True or False: Inhalant use can cause cold thermal burns. a. True

“The gases that are in aerosol cans are compressed and under high pressure. When they are released and they rapidly expand, the gases are cooled and can cause cold thermal injuries to the skin and the respiratory tract, in some cases significant enough to require endotracheal intubation.”

11. Toluene intoxication can cause b. renal tubular acidosis and hypokalemic paralysis.

“Acute toluene intoxication can cause hypokalemic paralysis and a normal anion gap metabolic acidosis…. Toluene is often used as a solvent in glue. Chronic toluene inhalation is a well-known cause of renal tubular acidosis.”

12. Sudden death from inhalant use is thought to be caused by c. ventricular arrhythmias.

“Deadly ventricular arrhythmias and sudden death caused by solvent use are well described in the medical literature but given the enormous number of incidents of huffing, sniffing, and bagging these effects are uncommon.”

13. Inhalants that contain ethylene glycol or methanol can cause d. metabolic acidosis.

“Some automotive products contain ethylene glycol and/or methanol, toxic alcohols that can cause metabolic acidosis.”

34 NurseCe4Less.com 14. Inhalants that contain methylene chloride can cause a. carbon monoxide poisoning.

“Paint strippers can contain methylene chloride. Methylene chloride is converted in vivo to carbon monoxide and carbon monoxide poisoning has been reported after accidental exposure to or improper use of paint strippers.”

15. Nitrite-based inhalants can cause b. methemoglobinemia.

“Symptomatic methemoglobinemia has been reported after nitrite use.”

16. True or False: Sympathomimetic drugs should not be used to treat ventricular arrhythmias caused by inhalants. a. True

“Sympathomimetic drugs such as epinephrine, isoproterenol, or norepinephrine should not be used to treat ventricular fibrillation (VF), ....”

17. Sudden death caused by inhalant use c. is very uncommon.

“Deadly ventricular arrhythmias and sudden death caused by solvent use are well described in the medical literature but given the enormous number of incidents of huffing, sniffing, and bagging these effects are uncommon.”

18. True or False: Irreversible cognitive or neurological damage can occur after chronic inhalant use. a. True

“Chronic solvent inhalation can cause serious, significant and irreversible neurological damage, cognitive, motor, and visual impairment.”

35 NurseCe4Less.com 19. Symptomatic methemoglobinemia is treated primarily by using b. methylene blue.

“There are two treatments that are most often used in patients with methemoglobinemia. They are methylene blue and ascorbic acid (vitamin C).”

20. The primary treatment for acute inhalant intoxication is d. symptomatic and supportive care.

“There is no specific treatment for health problems caused by chronic solvent use; patients should be treated with symptomatic and supportive care and the appropriate consultations.”

36 NurseCe4Less.com Reference Section

The References below include published works and in-text citations of published works that are intended as helpful material for further reading.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth ed. Alexandria, VA: American Psychiatric Association. 2013. 2. and Mental Health Services Administration. Recent declines in adolescent inhalant use. 2014; Retrieved from http://www.samhsa.gov/data/sites/default/files/sr174-inhalants- 2014/sr174-inhalants-2014/sr174-inhalants-2014.pdf. 3. Tormoehlen LM, Tekulve KJ, Nañagas KA. Hydrocarbon : A review. Clin Toxicol (Phila). 2014; 52(5):479-489. 4. Perry H. Inhalant abuse in children and adolescents. UpToDate. 2014; Retrieved from http://www.uptodate.com/contents/inhalant-abuse-in- children-and-adolescents. 5. Nguyen J, O'Brien C, Schapp S. Adolescent inhalant use prevention, assessment, and treatment: A literature synthesis. Int J . 2016; 31:15-24. 6. Ford JB, Sutter ME, Owen KP, Albertson TE. Volatile substance misuse: an updated review of toxicity and treatment. Clin Rev Allergy Immunol. 2014; 46(1):19-33. 7. Romolo, FS, et al (2017). Volatile lipophilic substances management in case of fatal sniffing. Journal of Forensic and Legal Medicine. Volume 52, November 2017, Pages 35-39. 8. Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract. 2011; 6(1):18-31. 9. National Inhalant Prevention Coalition. 2016; Retrieved from http://www.inhalants.org/laws.htm. 10. Crossin, R, et al (2019). The effect of adolescent inhalant abuse on energy balance and growth. Pharmacol Res Perspect. 2019 Aug; 7(4): e00498. 11. Tsao JH, Hu YH, How CK, et al. Atrioventricular conduction abnormality and hyperchloremic metabolic acidosis in toluene sniffing. J Formos Med Assoc. 2011; 110(10):652-654. 12. Samson R, Kado H, Chapman D. Huffing-induced cardiomyopathy: A case report. Cardiovac Toxicol. 2012; 12(1): 90-92. 13. Carder JR, Fuerst RS. Myocardial infarction after toluene inhalation. Pediatric Emergency Care. 1997; 13(2):117-119.

37 NurseCe4Less.com 14. De Naeyer AH, de Kort SW, Portegies MC, Deraedt DJ, Buysse CM. Myocardial infarction in a 16-year-old following inhalation of butane gas. [Article in Dutch]. Ned Tijdschr Geneeskd. 2011; 155(34):A3443. 15. Kopec KT, Brent J, Banner W, Ruha AM, Leikin JB. Management of cardiac dysrhythmias following hydrocarbon abuse: Clinical toxicology teaching case from NACCT acute and intensive care symposium. Clin Toxicol (Phila). 2014; 52(2):141-145. 16. Shepherd RT. Mechanism of sudden death associated with volatile substance abuse. Human Toxicology. 1989; 8(4):287-291. 17. Senthilkumaran S, Meenaakshisundaram R, Michaels AD, Balamurgan N, Thirumalaikolundusubramanian P. Ventricular fibrillation after exposure to – death is just a sniff away. J Electrocardiol. 2012; 45(2):164-166. 18. Bowen SE. Two serious and challenging medical complications associated with volatile substance misuse: sudden sniffing death and fetal solvent syndrome. Subst Use Misuse. 2011; 46 Suppl 1:68-72. 19. Kuhn JJ, Lassen LF. Acute upper airway obstruction following recreational inhalation of a hydrofluorocarbon propellant. Otolaryngol Head Neck Surg. 1996; 115(4):587-590.179. 20. Koehler MM, Henninger CA. Orofacial and digital frostbite caused by inhalant abuse. Cutis. 2014; 93(5):256-260. 21. Kurniali PC, Henry L, Kurl R, Meharg JV. Inhalant abuse of computer cleaner manifested as angioedema. Am J Emerg Med. 2012; 30(1):265.e3-e5. 22. Winston A, Kanzy A, Bachuwa G. Air Duster abuse causing rapid airway compromise. BMJ Case Rep. 2012; pii: bcr2014207566. doi: 10.1136/bcr-2014-207566. 23. Cabrera VJ, Farmakiotis D, Aggarwal V. Methylene chloride intoxication treated with hyperbaric oxygen therapy. Am J Med. 2011; 124(5):e3- e4. 24. Wallace EA, Green AS. Methanol toxicity secondary to inhalant abuse in adult men. Clin Toxicol (Phila). 2009; 47(3):239-242. 25. LoVecchio F, Sawyers B, Thole D, Beuler MC, Winchell J, Curry SC. Outcomes following abuse of methanol-containing carburetor cleaners. Hum Exp Toxicol. 2004; 23(10):473-475. 26. McCabe A, McCann B, Kelly P. Pop goes the O2: a case of popper- induced methemoglobinemia. BMJ Case Rep. 2012; pii: bcr2012007176. doi: 10.1136/bcr-2012-007176. 27. Cámara-Lemarroy CR, Gónzalez-Moreno EI, Rodriguez-Gutierrez R, González-González JG. Clinical presentation and management in acute toluene intoxication: a case series. Inhal Toxicol. 2012; 24(7):434- 438. 28. Camara-Lemarroy CR, Rodríguez-Gutiérrez R, Monreal-Robles R, González-González JG. Acute toluene intoxication - clinical

38 NurseCe4Less.com presentation, management and prognosis: a prospective observational study. BMC Emerg Med. 2015; 15:19. doi: 10.1186/s12873-015-0039- 0. 29. Tuchscherer J, Rehman H. Metabolic acidosis in toluene sniffing. CJEM. 2013; 15(4):249-252. 30. Kurbat RS, Pollack CV Jr. Facial injury and airway threat from inhalant abuse: a case report. J Emerg Med. 1998; 16(2): 167-169. 31. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015; 53(10): 961-1146. 32. Da Broi U, Colatutto A, Sala P, Desinan L. Medico legal investigations into sudden sniffing deaths linked with trichloroethylene. J Forensic Leg Med. 2015; 34:81-87. 33. Amadasi A, Mastroluca L, Marasciuolo L, et al. Death due to acute tetrachloroethylene intoxication in a chronic abuser. Int J Legal Med. 2015; 129(3):487-493. 34. Lim CS, Demeter BL, Leikin JB. Fatality after inhalation of methanol- containing paint stripper. Clin Toxicol (Phila). 2015; 53(4):411. doi: 0.3109/15563650.2015.1010684. 35. Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract. 2011; 6(1):18-31. 36. Mckee, R, Adenuga, M, Carrillo, J. Characterization of the toxicological hazards of hydrocarbon solvents. Critical Reviews in Toxicology. Crit Rev Toxicol, 2015; 45(4): 273–365. 37. Jain, R and Verma, A. Laboratory approach for diagnosis of toluene- based inhalant abuse in a clinical setting. J Pharm Bioallied. 2016 Jan- Mar; 8(1): 18–22. 38. Camara-Lemarroy, CR, Rodriguez-Gutierrez, R, Monreal-Robles, R, Gonzalez-Gonzalez, JG. Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study. BMC Emergency Medicine. 2015; volume 15, Article number: 19. 39. O’Malley, G and O’Malley, R. Volatile Solvents. Merck Manual Professional Version. 2018. Retrieved from https://www.merckmanuals.com/professional/special- subjects/recreational-drugs-and-intoxicants/volatile- solvents?query=glue%20sniffing 40. National Institute of Drug Abuse. Inhalants. NIH. Retrieved from https://www.drugabuse.gov/publications/research- reports/inhalants/what-are-short-long-term-effects-inhalant-use 41. Lewander, W, Aleguas, A. Hydrocarbon poisoning. Uptodate. 2019; Retrieved from https://www.uptodate.com/contents/hydrocarbon-

39 NurseCe4Less.com poisoning?search=emergency%20treatment%20adolescent%20inhala nt%20use&source=search_result&selectedTitle=2~81&usage_type=de fault&display_rank=2 42. Prchal, J. Clinical features, diagnosis, and treatment of methemoglobinemia. Uptodate. 2019; Retrieved from https://www.uptodate.com/contents/clinical-features-diagnosis-and- treatment-of- methemoglobinemia?search=Methylene%20blue%20is%20the%20anti dotal%20therapy%20for%20an%20elevated%20methemoglobin%20l evel&source=search_result&selectedTitle=1~150&usage_type=default &display_rank=1 43. Latus, J., Kimmel, M., Alscher, M., Braun, N. Ethylene glycol poisoning: a rare but life-threatening cause of metabolic acidosis—a single-centre experience. Clin Kidney J. 2012 Apr; 5(2): 120–123. doi: 10.1093/ckj/sfs009 44. Hawash, A, Travers, J, Gokce, S. Toxic cutaneous responses from inhalant abuse. JAAD Case Rep. 2019; 5(1): 31–33.

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