01Approach to the Critical Patient/attcp46

Immediate stabilization

›Airway and breathing priorities

›Airway protection assessment

›Depressed consciousness or stupor

›Vomiting or aspiration risk

›If unable to protect airway, proceed to definitive airway management with RSI

›Oxygen therapy

›High-flow O2 via non-rebreather for SpO2 < 94%

›Pulse oximetry continuous

›Respiratory failure triggers

›Apnea or agonal respirations

›Hypoxia unresponsive to supplemental O2

›Cardiovascular resuscitation

›Sudden sniffing death syndrome recognition

›Ventricular fibrillation or pulseless VT — immediate defibrillation

›Do NOT administer epinephrine as first-line due to catecholamine-sensitized myocardium

›Beta-blockers presumed protective in VF/VT from inhalant exposure

›Hemodynamic instability

›IV access x2 large bore

›Normal saline bolus for hypotension

›Avoid vasopressors with sympathomimetic activity in acute phase

›Continuous cardiac monitoring mandatory for all suspected inhalant exposures

Critical pearls and pitfalls

›Do not agitate or startle the patient

›Catecholamine surge can precipitate fatal ventricular dysrhythmia

›Calm environment; minimize physical restraint

›Approach with verbal de-escalation first

›ECG mandatory on all presentations

02History/hx66

Exposure characterization

›Method of inhalation

›Huffing (inhaling from rag soaked with solvent)

›Sniffing (directly from container)

›Bagging (inhaling from plastic bag placed over head or mouth — suffocation risk)

›Substance class

›Aromatic hydrocarbons: toluene (paint thinner, glue), benzene (gasoline)

›Halogenated hydrocarbons: 1,1-difluoroethane (keyboard dusters), fluorocarbons

›Aliphatic hydrocarbons: n-hexane (glue), butane and propane (lighter fluid)

›Ketones and esters: acetone (nail polish remover)

›Nitrites (poppers): amyl, butyl, isobutyl nitrite — separate mechanism

›Timeline and duration

›Rapid onset of intoxication: seconds to minutes after inhalation

›Rapid recovery: acute intoxication typically resolves within 30–60 minutes

›Frequency, duration, and escalation of use pattern

›First-time versus chronic use

Symptoms and alarm features

›Acute intoxication symptoms

›Euphoria, disinhibition

›Dizziness, headache, tinnitus

›Ataxia, incoordination

›Hallucinations (auditory and visual)

›Nausea and vomiting

›Confusion or altered mental status

›Alarm features

›Syncope or cardiac arrest during or immediately after use

›Chest pain or palpitations

›Severe weakness (rhabdomyolysis)

03Physical Exam/exam44

Vital signs and general appearance

›Vital signs pattern

›Tachycardia (common in acute intoxication and arrhythmia)

›Hypotension (shock, dehydration)

›Tachypnea (aspiration, metabolic acidosis compensation)

›Hypoxia (aspiration pneumonitis, respiratory depression)

›Hypothermia possible (exposure, compressed gas frostbite)

›General appearance

›Level of consciousness: alert vs. confused vs. stuporous vs. comatose

›Chemical odor on breath or clothing (solvent smell)

›Paint or pigment stains on hands, face, or clothing

Head, eyes, ears, nose, throat

›HEENT findings

›Perioral or perinasal erythematous eczematous dermatitis (glue-sniffer's rash)

›Conjunctival injection or lacrimation

›Frostbite lesions around mouth or nose (from compressed gas propellants)

›Nystagmus

›Slurred speech

Neurological examination

›Mental status

›Glasgow Coma Scale

›Disorientation, confusion, psychomotor retardation

›Stupor or coma in severe cases

›Motor and coordination

›Ataxia, unsteady gait

›Tremor

›Depressed deep tendon reflexes

›Peripheral neuropathy findings (n-hexane): distal weakness, stocking-glove sensory loss

04Differential Diagnosis/ddx48

Life-threatening differentials

›Cardiac emergencies

›Ventricular fibrillation or ventricular tachycardia

›Sudden sniffing death — catecholamine-sensitized myocardium

›ICD-10 I49.01 — ventricular fibrillation

›Toxic myocarditis

›ST changes and troponin elevation

›ICD-10 I40.1 — isolated myocarditis

›Neurological emergencies

›Hypoglycemia

›Point-of-care glucose mandatory in all altered mental status

›ICD-10 E11.641

›Head trauma

›Found down with unknown mechanism

›CT head if focal findings or GCS < 13

›Carbon monoxide poisoning

›Altered mental status, headache

›Carboxyhemoglobin level differentiates

›Metabolic emergencies

›Severe hypokalemia from toluene

›Mean K+ 1.7 mmol/L in toluene case series (Streicher et al.)

›Cardiac arrest risk

›Rhabdomyolysis

›Pigmented urine, elevated CK

›Acute kidney injury risk

Substance intoxication mimics

›Alcohol intoxication

›Similar CNS depression; ethanol level positive

05Laboratory Tests/lt49

Core metabolic panel

›Basic or comprehensive metabolic panel

›Hypokalemia (toluene causes renal tubular acidosis with K+ wasting)

›Mean K+ 1.7 mmol/L reported in toluene series (Streicher et al.)

›Severe hypokalemia is a cardiac arrest precipitant

›Hypophosphatemia (concurrent electrolyte derangement)

›Hyperchloremic non-anion gap metabolic acidosis (toluene-induced distal RTA)

›Elevated creatinine and BUN (renal injury)

›Arterial or venous blood gas

›pH and bicarbonate for metabolic acidosis severity

›pCO2 mmHg for ventilatory status

›Lactate for tissue hypoperfusion (>= 2 mmol/L concerning)

Cardiac markers

›Troponin

›Indication: chest pain, ECG changes, or suspected myocarditis

›Elevation suggests toxic myocarditis or demand ischemia

›ECG (mandatory)

›QTc prolongation

›ST-segment changes

›Ventricular ectopy, VT, or VF

›BNP or NT-proBNP

›If cardiomyopathy suspected in chronic users

›Heart failure differentiation

Muscle and organ injury markers

›Creatine kinase (CK) and myoglobin

›Rhabdomyolysis screening (CK > 5000 U/L significant)

›Serial CK if elevated at presentation

›Urinalysis

06Diagnostic Tests/dt59

Scoring Systems

›Inhalant intoxication severity assessment

›No validated scoring system specific to inhalant intoxication in emergency medicine

›Clinical severity stratification guides disposition

›Mild: alert, normal ECG, resolving symptoms

›Moderate: altered mental status, ECG changes, electrolyte derangements

›Severe: coma, arrhythmia, cardiac arrest, multi-organ failure

›DSM-5 criteria for inhalant use disorder

›Inhaled hydrocarbon substance use causing clinically significant impairment

›At least 2 of 11 criteria within 12 months

›Tolerance, craving, continued use despite harm

›Failure to fulfill role obligations

›Severity: mild 2–3 criteria, moderate 4–5, severe >= 6

›CRAFFT screening tool (adolescents)

›6-question validated screen for substance use in patients aged 12–21

›Score >= 2 positive screen requiring further assessment

›Car, Relax, Alone, Forget, Friends, Trouble

MRI

›Brain MRI indications

›Chronic inhalant use with cognitive decline or neurological symptoms

›Persistent neurological deficits after acute intoxication clears

›Not indicated for uncomplicated acute intoxication

›Characteristic findings in chronic toluene leukoencephalopathy

›Diffuse periventricular and subcortical white matter T2 hyperintensities

›Loss of gray-white matter differentiation

›Corpus callosum thinning

›Cerebral and cerebellar atrophy

›Ventricular dilation

07Disposition/dispo32

Admission criteria

›ICU admission indications

›Ventricular arrhythmia requiring continuous monitoring or intervention

›Cardiac arrest resuscitated

›Coma or GCS <= 8 requiring airway protection

›Severe metabolic acidosis pH < 7.2

›Multi-organ failure (cardiac, renal, hepatic)

›Rhabdomyolysis with acute kidney injury

›Telemetry or monitored observation indications

›ECG abnormalities (QTc prolongation, ST changes, ectopy)

›Moderate electrolyte derangements requiring correction

›Moderate altered mental status with improving trajectory

›Suicidal ideation or psychiatric co-morbidity requiring safety evaluation

Discharge criteria

›Safe discharge requirements

›Complete clinical resolution of intoxication

›Normal ECG (QTc, no ectopy, no ST changes)

›Normal or corrected electrolytes

›Normal mental status at baseline

›Safe disposition environment with supervision

›Reliable follow-up arranged

›Observation period

›Minimum 4–6 hours of cardiac monitoring after last known exposure

›Extend observation if ECG changes or electrolyte derangements

Consult and follow-up

›Mandatory consults before discharge

›Social work or child protective services for minors without safe environment

›Psychiatry if suicidal ideation, self-harm, or psychiatric co-morbidity

08Treatment/t60

Immediate resuscitation

›Airway management

›Supplemental O2 via non-rebreather mask

›Target SpO2 >= 94%

›High-flow O2 does not exacerbate inhalant toxicity

›Rapid sequence intubation for airway failure

›Ketamine or etomidate for induction

›Succinylcholine or rocuronium for paralysis

›Avoidance of succinylcholine if rhabdomyolysis with severe hyperkalemia

›Cardiac arrest management

›Immediate defibrillation for VF or pulseless VT

›200 J biphasic for initial shock

›Standard ACLS algorithm with critical modification

›Avoid epinephrine as first-line vasopressor in catecholamine-sensitized myocardium

›Class concern: epinephrine may precipitate recurrent VF in inhalant-sensitized myocardium

›AHA 2025 guidelines note avoidance of sympathomimetics in hydrocarbon toxicity

›Beta-blockers for ventricular arrhythmia

›Esmolol IV 500 mcg/kg bolus over 1 minute, then 50–200 mcg/kg/min infusion

›Titrate by 50 mcg/kg/min every 4 minutes to response

›Maximum 300 mcg/kg/min

›Propranolol IV 1 mg over 1 minute; repeat every 2 minutes to maximum 5 mg (adults)

›Mechanism: beta-blockade reduces catecholamine-mediated sensitization of myocardium

Supportive care

›Agitation management

›Calm environment — minimize stimulation to prevent catecholamine surge

›Verbal de-escalation preferred

›Benzodiazepines for refractory agitation

›Lorazepam IV 1–2 mg (adult); 0.05–0.1 mg/kg IV in pediatrics

›Diazepam IV 5–10 mg (adult); 0.1–0.2 mg/kg IV in pediatrics

›Note: risk of respiratory depression with co-ingestion

›Avoid physical restraint if possible (catecholamine surge risk)

›Antiemetics

›Ondansetron IV 4 mg (adult) or 0.1 mg/kg IV (pediatric, max 4 mg)

›Aspiration precautions with vomiting

›Head of bed elevation 30–45 degrees

Electrolyte and fluid management

›IV fluid resuscitation

›Normal saline or lactated Ringer's 20–30 ml/kg bolus for dehydration or hypotension

›Aggressive fluid resuscitation for rhabdomyolysis

›Target urine output >= 200–300 ml/hr during rhabdomyolysis

›Consider urine alkalinization (sodium bicarbonate) for severe myoglobinuria

›Potassium replacement

›Toluene-induced hypokalemia requires aggressive repletion

›IV potassium chloride 10–20 mmol/hr via central line for severe hypokalemia (K+ < 2.5 mmol/L)

›Oral potassium supplementation if mild (K+ 2.5–3.5 mmol/L) and tolerating PO

›Monitor ECG continuously during rapid repletion

›Phosphate replacement

›Hypophosphatemia concurrent with toluene-induced RTA

›IV potassium phosphate 0.08–0.24 mmol/kg over 4–6 hours for severe hypophosphatemia

›Metabolic acidosis

›Non-anion gap metabolic acidosis (toluene-RTA): potassium and sodium bicarbonate repletion

›IV sodium bicarbonate 1–2 mmol/kg IV for pH < 7.1 or severe acidosis

No reversal agent

›No specific antidote exists for inhalant intoxication

›Treatment is entirely supportive

›Cochrane review (Konghom et al., 2010): insufficient evidence for any pharmacotherapy for inhalant use disorder

›No FDA-approved pharmacotherapy for inhalant use disorder

Substance use intervention

›Brief motivational intervention

›CRAFFT results debrief in adolescents

›Non-judgmental counseling on sudden death risk even with first use

›Referral pathways

›Addiction medicine or adolescent substance use program

›Cognitive behavioral therapy (most supported non-pharmacological approach)

›Multisystemic therapy for adolescents

09Special Populations/sp49

Pregnancy

›Maternal risks

›Toluene embryopathy: fetal abnormalities from chronic toluene inhalation

›Growth restriction, microcephaly, dysmorphic facies

›CNS abnormalities including intellectual disability

›Acute intoxication increases aspiration risk due to reduced lower esophageal sphincter tone

›Maternal cardiac arrest — immediate defibrillation regardless of gestational age

›Fetal and neonatal risks

›Toluene-exposed neonates: hyperchloremic metabolic acidosis, renal tubular dysfunction

›Preterm birth risk with acute toxic exposures

›Neonatal withdrawal has been described

›Management modifications

›Urine pregnancy test mandatory in all females of reproductive age

›Fetal monitoring if viable gestation

›Obstetric consultation for significant maternal compromise

›Avoid benzodiazepines in first trimester if possible (teratogen risk); use lowest effective dose in acute agitation

›No safe level of inhalant use in pregnancy — counseling mandatory

Geriatric

›Prevalence and presentation

›Inhalant abuse less common in older adults but underrecognized

›Nitrite (poppers) use occurs in older gay men for sexual enhancement

›Occupational solvent exposure may co-occur

›Altered physiology

›Reduced cardiac reserve increases risk of fatal arrhythmia at lower exposures

›Reduced renal function impairs electrolyte correction

›Polypharmacy interactions: QTc-prolonging drugs compound arrhythmia risk

›Cognitive baseline confusion makes mental status assessment complex

›Management modifications

10Background/b66

Epidemiology

›Prevalence

›Nearly 20% of middle and high school students have experimented with inhaled substances

›Approximately 1 million new users per year in the United States

›Second only to cannabis as most commonly used illicit substance in pre-teen population

›Demographics

›Peak onset 12–15 years; most common first substance in young adolescents

›Male predominance in mortality (72% male in one case series)

›Girls increasingly misusing at equal or higher rates than boys

›Disproportionate prevalence in low-income, rural, and Indigenous communities

›Mortality

›Sudden sniffing death syndrome responsible for approximately 50% of inhalant-related fatalities

›Can occur with first-ever use

›Australian study (Berling et al., 2023): 8% severe outcomes in ambulance attendances

›Substance categories

›Four major categories: volatile solvents, aerosols, gases, and nitrites

›Most abused: paint thinner, glue, aerosol sprays, keyboard dusters, gasoline, lighter fluid

›ICD-10: F18.x — Inhalant-related disorders; T59 — Toxic effects of other gases and vapors

Pathophysiology

›Mechanism of acute intoxication

›Volatile hydrocarbons are highly lipophilic

›Rapid absorption across alveolar membrane

›Blood-brain barrier penetration within seconds

›CNS depression via GABA potentiation and NMDA receptor inhibition

›Similar mechanism to alcohol and anesthetic agents

›Euphoria and disinhibition at low concentrations

›CNS depression, stupor, and coma at high concentrations

›Sudden sniffing death syndrome mechanism

›Catecholamine-sensitized cardiac arrhythmia

›Volatile hydrocarbons sensitize myocardium to endogenous catecholamines

›Physical exertion, fright, or confrontation triggers sympathetic surge

›Resulting ventricular fibrillation or ventricular tachycardia

›Can occur with first exposure or any subsequent use

›All classes of volatile hydrocarbons capable of this mechanism

›Toluene-specific toxicity

›Renal tubular acidosis type 1 (distal) — impaired H+ excretion

›Hyperchloremic non-anion gap metabolic acidosis

›Severe hypokalemia (K+ wasting)

›Hypophosphatemia

›Chronic CNS toxicity: cerebral and cerebellar atrophy, leukoencephalopathy

›n-Hexane neuropathy

›Metabolized to 2,5-hexanedione (neurotoxic)

›Axonal degeneration: dying-back peripheral neuropathy

›Stocking-glove sensory loss, distal muscle weakness progressing proximally

›Organ-specific toxicity

›Hepatotoxicity: chlorinated solvents (carbon tetrachloride, chloroform) — centrilobular necrosis

›Aplastic anemia: chronic benzene exposure — bone marrow suppression

›Nephrotoxicity: toluene renal tubular acidosis, glomerulonephritis

›Cardiomyopathy: chronic hydrocarbon exposure — dilated pattern

Therapeutic Considerations

›No antidote — entirely supportive care

›Cochrane review (Konghom et al., 2010): no pharmacotherapy with proven efficacy for inhalant use disorder

›No FDA-approved treatment for inhalant use disorder

›Catecholamine avoidance is the critical therapeutic principle

›All sympathomimetics contraindicated in acute setting

›Epinephrine — absolute contraindication in suspected inhalant-related VF

›Norepinephrine — relative contraindication, use only if no alternative for refractory shock

›AHA 2025 CPR guidelines: avoidance of epinephrine in hydrocarbon-mediated arrhythmia

›Beta-blockade for arrhythmia

›Theoretical basis: block catecholamine sensitization of myocardium

›Evidence is based on animal models and case reports (not RCTs)

›Esmolol preferred (short half-life, titratable)

›Electrolyte disturbances are critical therapeutic targets

›Toluene hypokalemia: aggressive potassium repletion before cardiac arrest risk

›Monitor ECG continuously during repletion

›Long-term treatment

›Cognitive behavioral therapy — most evidence-supported psychological intervention

›Multisystemic therapy — evidence in adolescent populations

›Community-based prevention and supply reduction programs

11Patient Discharge Instructions/pdi26

copy discharge instructions

›What is inhalant abuse?

›Inhalant abuse means intentionally breathing chemical fumes from household products to get high

›Common products include paint thinner, glue, aerosol sprays, keyboard dusters, and gasoline

›These chemicals can cause sudden death even with the very first time they are used

›Why is this so dangerous?

›Inhalants cause sudden cardiac arrest (sudden sniffing death syndrome) without warning

›This can happen with the very first use and during any subsequent use

›Standard drug tests will not detect inhalants, so a normal drug test does not mean it is safe

›Return to the emergency department immediately if you experience any of the following

›Chest pain, pounding heartbeat, or irregular heartbeat

›Fainting or loss of consciousness

›Difficulty breathing or shortness of breath

›Severe muscle weakness or inability to walk

›Confusion, severe headache, or inability to be roused

›Dark brown or tea-colored urine (sign of muscle breakdown)

›Any return of symptoms after leaving the emergency department

›Medications and activity after discharge

›Do not use any inhalants, solvents, or aerosol sprays intentionally

›Do not combine inhalants with alcohol or any other substances

›Rest and increase fluid intake over the next 24–48 hours

›Follow-up with your family doctor or addiction medicine specialist within 1–2 weeks

›For parents and caregivers

›Secure household chemicals and aerosol products to reduce access

›Learn warning signs: chemical odor on breath or clothing, paint stains, empty aerosol cans

›Inhalant abuse is not detected on standard school or workplace drug tests

›Speak with a healthcare provider or addiction specialist about prevention resources

12References/r30

Guidelines and key sources

›Anderson CE, Loomis GA. Recognition and Prevention of Inhalant Abuse. American Family Physician. 2003. PMID 13678134

›Epidemiology, methods of use, pregnancy risks, prevention strategies

›Ford JB, Sutter ME, Owen KP, Albertson TE. Volatile Substance Misuse: An Updated Review of Toxicity and Treatment. Clinical Reviews in Allergy and Immunology. 2014. PMID 23649409

›Comprehensive toxicology review, organ systems, physical exam findings, clinical management

›Tormoehlen LM, Tekulve KJ, Nangas KA. Hydrocarbon Toxicity: A Review. Clinical Toxicology. 2014. PMID 24911841

›Pathophysiology, sudden sniffing death, catecholamine sensitization, disposition

›Berling I, Isbister GK. Rare but Relevant: Hydrocarbons and Sudden Sniffing Syndrome. Addiction. 2025. PMID 40275758

›Mechanism of sudden sniffing death; rapid onset and recovery data

›Berling I, Chiew A, Brown J. Poisonings from Hydrocarbon Inhalant Misuse in Australia. Addiction. 2023. PMID 36776135

›Epidemiology and acute outcomes in ambulance attendance cohort

›Streicher HZ, Gabow PA, Moss AH, Kono D, Kaehny WD. Syndromes of Toluene Sniffing in Adults. Annals of Internal Medicine. 1981. PMID 7235417

›Classic paper: toluene-RTA, mean K+ 1.7 mmol/L, electrolyte derangements

›Fogelson B, Qu D, Bhagat M, Branca PR. Multi-Organ System Failure Secondary to Difluoroethane Toxicity in a Patient Huffing Air Duster. Journal of Addictive Diseases. 2022. PMID 35044291

›Multi-organ failure from keyboard duster (1,1-difluoroethane); electrolyte findings

›Konghom S, Verachai V, Srisurapanont M, et al. Treatment for Inhalant Dependence and Abuse. Cochrane Database of Systematic Reviews. 2010

›No pharmacotherapy with proven efficacy; basis for supportive-only treatment recommendation

›Cairney S, O'Connor N, Dingwall KM, et al. A Prospective Study of Neurocognitive Changes 15 Years After Chronic Inhalant Abuse. Addiction. 2013. PMID 23490054

›Long-term neurocognitive sequelae; partial recovery with prolonged abstinence

›Cao D, Arens AM, Chow SL, et al. Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care. Circulation. 2025

›AHA 2025 guideline: avoidance of sympathomimetics in hydrocarbon-mediated arrhythmia

›Flanagan RJ, Ruprah M, Meredith TJ, Ramsey JD. An Introduction to the Clinical Toxicology of Volatile Substances. Drug Safety. 1990. PMID 2222869

›Foundational toxicology; nitrite and solvent classification

›Jupina M, Weleff J, Harp J, Anand A. Cognitive, Imaging, and Psychiatric Changes Associated With Chronic Toluene Use. Journal of Addictive Diseases. 2024. PMID 37503800

›MRI findings in chronic toluene leukoencephalopathy; psychiatric co-morbidities

›Nguyen J, O'Brien C, Schapp S. Adolescent Inhalant Use Prevention, Assessment, and Treatment: A Literature Synthesis. International Journal on Drug Policy. 2016. PMID 26969125

›Adolescent-specific epidemiology, CRAFFT screening, prevention strategies

›Kim J, Choe S, Shin I, et al. Analytical Methods for Detecting Butane, Propane, and Their Metabolites in Biological Samples. Journal of Chromatography B. 2024. PMID 38277722

Evidence & Review

Evidence & Review