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INHALANTS
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Guidelines FOR MEDICAL EXAMINERS, CORONERS AND PATHOLOGISTS: DETERMINING INHALANT DEATHS

INTRODUCTION
Every year an untold number of individuals die as a result of intentionally inhaling common, legal, everyday home, school and office products. The National Inhalant Prevention Coalition (NIPC) reports approximately 100 to 125 inhalant deaths per year, based on contacts with families of victims and media accounts. However this does not provide an accurate picture of the full extent of this public health problem.

Inhalant abuse related fatalities are underreported because they may not be recognized as such or because of a perceived stigma. Doctors and medical staff are traditionally one of the professions most focused on their continuing medical education using Medscape, medical journals, and other resources available to them, but even with all of that research it can be difficult for them to accurately identify signs of inhalant use. Therefore, The National Inhalant Prevention Coalition (NIPC) is providing background information and guidelines to assist medical examiners, coroners, pathologists and toxicologists to better understand, to recognize, to document and to accurately report inhalant deaths.

Why is this needed?
* To better define the true scope of the problem;
* To track regional variations;
* To evaluate preventive interventions
* To evaluate treatment interventions

Background:
What are inhalants?
Inhalants are chemical vapors or gases that produce psychoactive (mind-altering) effects when abused or misused by concentrating and intentionally inhaling these fumes. These include volatile organic solvents, fuel gases, nitrites, and anesthetic gases.

Inhalants are volatile organic chemicals. Volatility is a measure of the tendency to vaporize or leave the liquid state. The most common inhalant chemical groups are the aliphatic and aromatic hydrocarbons, which are widely distributed in nature, primarily in natural gas and petroleum. Examples include: toluene, benzene, xylene and hexane. Another group of inhalants is comprised of hydrocarbons with attached halogen ions. Examples are trichloroethylene and the freons. Another group of inhalants is anesthetic gases such as ether, nitrous oxide, chloroform and halothane.

Once commonly referred to as "glue sniffing," inhalant abuse now includes a broad range of volatile solvents and gas products (e.g. model airplane glue, paint thinner, gasoline, and nail polish remover), aerosols (e.g. nonstick cooking spray, computer keyboard cleaner and hair spray), anesthetics (e.g., nitrous oxide or "laughing gas" and ether), and nitrites (e.g. amyl, butyl, and isobutyl nitrites, often marketed as "poppers" or room odorizers). Other powdered drugs, such as heroin, cocaine, and methamphetamine, can be inhaled but are not considered inhalants. Although the chemicals involved and their effects vary, the route of administration is the common factor

What Types of Products Can Be Abused?
* General Supplies—cements and glues; correction fluid; magic markers;
solvent-based dry erase markers
* Cleaning Supplies—any product in an aerosol can; aerosol air fresheners and deodorizers; computer air duster
* Wood Shop—paints; varnishes; stains; paint thinner; contact cement
* Art Supplies—rubber cement; printing inks; spray paints and clear finishes
* Auto—degreasers; spray lubricants; "Fix-a-Flat" type products; solvents; Freon®; brake fluid; gasoline; lacquers; lacquer; thinners
* Health and Beauty—nail polish and nail polish remover; hair spray; deodorants
* Cooking Supplies—cooking spray; whipping cream in aerosol cans; whipping cream cartridges (whippets)

What are the most common modes of administration?
Inhalants are abused either by "sniffing" though the nose or inhaling fumes through the open mouth ("huffing") much like a smoker inhales cigarette smoke. Usually the open tube of glue, nail polish, or marker is placed close to the nose and the fumes are inhaled.

People who abuse inhalants may also spray the substance into a plastic or paper bag and huff that way ("bagging") or even place the bag over their entire head.

Often a product will be poured or sprayed on a piece of cloth, a rag, a towel, or a shirt sleeve or into a soda can and inhaled in that manner.

Another method is to paint the fingernails with a product like correction fluid and inhale the substance on the nails.

Sometimes an aerosol substance is sprayed directly into the mouth.

Substances can also be placed into alternative containers (e.g., balloon filled with nitrous oxide) or heated first and then inhaled

Who is likely to abuse inhalants?
Contrary to popular perception, people who abuse inhalants are found in many segments of the population and no one group can be categorized as
"inhalant abusers." In 2002, more than 22.8 million Americans reported ever having used an inhalant, and about 180,000 were estimated to need treatment because they were dependent on or abused inhalants. according to Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2002 National Survey on Drug Use and Health (NSHUH).

People who abuse inhalants are seen in emergency rooms. According to the SAMHSA’s 2002 Emergency Department Trends from the Drug Abuse Warning Network (DAWN), Final Estimates 1995 - 2002 report, which reflects reports from hospital emergency departments, there were 1,496 inhalant related mentions. This is an increase from 522 mentions in 2001 – a 186.6% increase (however, inhalant mentions tend to fluctuate from year to year).

Frequency:
According to the University of Michigan’s 2003 National Monitoring the Future Survey, 11.2% of US high-school seniors reported previous inhalant use. The US Substance Abuse and Mental Health Administration’s 2002 National Survey on Drug Use and Health reported over 22.8 million persons had used inhalants, of which more than 2.6 million were between the ages of 12 and 17.

Some studies indicate that inhalant abuse precedes tobacco or alcohol use. Although most teenagers outgrow inhalant use, many may progress to "harder" drugs in their teens or even use them concurrently with inhalants. Some inhalant abusers continue use into adulthood.

Unique risk groups for adults include nurses, dentists, anesthesiologists, air conditioning repairers, shoemakers, hair stylists, painters, and dry-cleaning workers, because of access to these chemicals or anesthetics in the workplace. Adults seek both the "high" offered by these agents, plus the reportedly aphrodisiac effects. Nitrite inhalant use is prevalent among homosexual males, but use has decreased with the AIDS epidemic.

Internationally, inhalant abuse is rampant among "street" children in many urban centers, in both developed and developing countries, and represents a global health issue.

Race:
These drugs have no social or geographic boundaries, but young children who abuse inhalants tend to be of lower socioeconomic class, poor school
performers with high rates of absenteeism or suspension, and from broken
families.
* Inhalant abuse among children has been associated with higher rates of
parental alcoholism and drug use. Users typically have low self-esteem and emotional problems (anxiety, depression, and anger).
* Inhalant abusers also have been associated with criminal activity and tend to have more family members in prison than non abusing children.

Though Caucasian children and adults are the predominant abusers of inhalants, other racial groups at increased risk include Hispanics and Native Americans. Most chronic inhalant abuse is associated with poverty and deprivation rather than race. Inhaling is frequently a group activity, occurring at school or at parties.

Gender:
In the past inhalant abuse tended to be more prevalent in males. However, over the past decade, abuse has increased in young females, and prevalence is nearly equal today in the youth population. Additionally, according to the 2002 NSDUH, girls begin inhalant use far earlier than boys with a mean age of first use at 15.0 years, as compared to 16.3 years for boys. Among adults, inhalant abuse is more a male activity.

Age:
The typical abusers of inhalants are 10-to-15-year-olds, though use in children as young as 7 and 8 years has been reported. Some studies indicate that the average age of initial use of these chemicals is about 12. Experimentation typically occurs in late childhood and is short lived.

Chronic abuse is usually seen in older adolescents, though it has also been reported in individuals as old as 50 or 60.

Why are inhalants popular?
Most inhalants are readily available, inexpensive or free, and usually legal to purchase and possess. The high is achieved within seconds and the effect dissipates within a half of an hour. Because products are easy to conceal and are useful everyday products (e.g., permanent markers, correction fluid) that are found in homes, offices, and schools, it is difficult to prevent access to them. And, because abusable products are so common, many youth do not perceive them as harmful and do not understand the consequences of using them.

What do inhalants do?
Inhalants provide an instant "rush" and, like alcohol, cause euphoria followed by central nervous system depression. Deep breathing of the toxic vapors may result in losing touch with one’s surroundings, a loss of self-control, violent behavior, nausea, unconsciousness, giddiness, loss of inhibition, loss of appetite, and, at higher doses, hallucinations. Inhalants can cause loss of motor skills, slurred speech, heart palpitations, seizures, nausea and vomiting. Signs of inhalant abuse include "huffer’s rash" or drying and redness around the mouth and nose, spots or sores around the mouth and red or runny eyes or nose. However, these findings are very uncommon even in chronic inhalant abusers. More common ones are paint or stains on the body or clothing; chemical breath odor; drunk, dazed, or dizzy appearance; an unexplained collection of abusable products; anxiety, excitability, and irritability.

The debilitating and potentially lethal effects of inhalants can occur even with first use. Sudden sniffing death syndrome is usually caused by the irregular heart rate induced by inhalants; other cardiac effects are hypertension, tachycardia, and bradycardia. Other significant effects include command seizures. Brain damage can be a consequence of chronic use.

Additional inhalant dangers are suffocation (e.g., from bagging), fire-related injuries from inhalant combustion (especially if the inhalant is heated or a cigarette is lit in a closed area where the inhalant is being abused), and accidents related to impaired judgment, lack of motor skills, or high-risk behavior.

What are the long-term effects of inhalant abuse?
Solvents are easily absorbed from the blood into lipid-rich tissues.
Chronic inhalant abuse can damage the brain, the heart, lungs, kidney, liver, and peripheral nerves.

To get involved in helping with people living with these long term effects, a respiratory therapist school can get you on the fast track.

Continued, chronic inhalant abuse has been associated with neurological
damage. People who abuse inhalants chronically have demonstrated a range
of mental dysfunction, from mild cognitive impairment (e.g., lack of
concentration or attention, poor memory, and poor learning skills) to
severe. In some instances these effects are permanent while in others they resolve after a long period of abstinence. Personality disorders, particularly antisocial personality, violent behavior, and depression, have been associated with inhalant abuse.

Pathophysiology:
Inhalants are highly lipid soluble. They easily cross both alveolar membranes and the blood-brain barrier. Exposure via the pulmonary route avoids first-pass hepatic metabolism. Onset of effect is seen in seconds. Volatiles accumulate in the brain (as well as other fatty tissues in the body). The mechanism of their effects is not entirely clear; some authors suggest that the mechanism is "fluidization" or change in solubility of neuronal cell membranes. The potency of these drugs seems to be related to their solubility in water. Other actions proposed include specific molecular ion channels, whereby these chemicals would potentiate the effects of GABA on the GABA-A receptors.

Inhaled concentration depends on the mode of administration. Sniffing
offers the lowest concentration, while bagging the highest. Huffing these chemicals produces an inhaled concentration between that of sniffing and bagging.

These agents have a high volume of distribution and several modes of elimination. With only a few important exceptions, elimination occurs primarily through the lungs. These exceptions include the alkyl nitrites, aromatics (like benzene), and methylene chloride, which undergo significant hepatic metabolism. In some instances, their metabolites can be toxic with examples including free nitrites and carbon monoxide.

Mortality/Morbidity
Inhalant abuse is associated with significant morbidity and mortality rates. Use of inhalants can result in death. Bowen reported 39 deaths in Virginia between 1987 and 1996 from acute voluntary exposure to inhalants. Median age was 19 years with 46% of the cases involving butane or propane. Maxwell reported 144 deaths in Texas between 1988 and 1998 in which use or abuse of inhalants was mentioned on the death certificates. Median age was 24, and 35% of the cases involved chlorofluorocarbons or Freon®.

CAUSES OF DEATH:
* Sudden Sniffing Death:
* Suffocation
* Trauma:
* Choking:
* Asphyxia:

INHALANT DEATH CONSIDERATIONS:
Inhalants should be considered as a cause of death where there is a high index of suspicion of inhalant use from clinical history and thorough scene investigation. This is especially true if there is no apparent cause of death at the scene. As this process continues it is very important that there be proper specimen (autopsy) selection and collection for analysis (provide toxicology laboratory with decedent’s history to facilitate analysis). Ensure that there is a consistency in reporting, at least within the same office and/or geographical area.

A systematic approach is required to determine that inhalants were a cause of death. Specifically:
* Investigation of circumstances;
* Death scene evaluation; and
* Sophisticated analytical toxicology.

SCENE INVESTIGATION:
The purpose of this is to ensure that all information pertinent to determining the cause, manner and circumstances of a potential inhalant fatality are considered in all investigations.

The death scene investigation is an essential and critical component of a thorough investigation of a suspected inhalant death. Information gathered during a thorough scene investigation augments that obtained from an autopsy and a clinical history review. The collection of specific products at the death scene will help narrow and focus the toxicological investigation and assist the pathologist, medical examiner or coroner in ruling in or ruling out illicit inhalant use as a cause of death.

The death scene investigation must include thorough and systematic search of the area to determine whether there were chemical or aerosol containers or canisters present or in the vicinity of the incident. Likewise, a thorough investigation should be made to determine if inhalant paraphernalia are present (e.g. plastic bags, balloons, towels, soda cans with paint stains, etc.). The victim’s face should be checked for paint stains as well as their fingernails to determine if a typewriter correction fluid type of substance is present.

CLINICAL CONSIDERATIONS:
History:
Inhalant abuse should be a consideration in any child, adolescent or young adult who dies of inexplicable aspiration of his or her gastric contents. It should also be a consideration for traumatic deaths in this age group. Inhalants can be associated with virtually any type of trauma including motor vehicle crashes, falls, fire, suicide and violence.

However the commonest cause of inhalant abuse death presents the greatest challenge. This is the sudden sniffing death syndrome. The typical scenario is the victim, while under the influence of an inhalant, is suddenly threatened, (such as being discovered by an individual of authority) or by a particularly frightening hallucination. The individual begins to flee and suddenly collapses and dies at the scene. The pathophysiology has been determined in experimental animals. All inhalants are cardiac depressants. Inhalant induced bradycardia predisposes to dysrhythmiae and the adrenalin surge associated with the fight or flight response of a threatening situation is the trigger for a fatal ventricular rhythm disturbance. Autopsy findings are completely unremarkable and establishing this diagnosis is dependent upon finding evidence of inhalants in post-mortem blood specimens.

* The following tables are provided as additional resources. Table 1
lists the chemicals commonly found in several commercial products that
often are abused. Table 2 lists unique clinical effects of several of
the major substances abused. (* Adapted from Miller and Gold, 1991)

Table 1. Chemicals Found in Specific Products

Product

Chemicals Found

Balsa wood cement Ethyl acetate
Contact adhesives Toluene, hexane, esters
Cryoquick spray 1,1,1 Tetrafluoroethane
Bicycle tire adhesive Toluene, xylenes
PVC cement Trichloroethylene
Air freshener, deodorants, fly spray, hair lacquer, spray paints Halons, butane, dimethyl ether
Anesthetics/analgesics Nitrous oxide, ether, chloroform
Commercial dry cleaning 1,1,1-Trichloroethane,
tetrachloroethylene, trichloroethylene
Fire extinguishers Bromochlorodifluoromethane,
halons 11 & 12
Cigarette lighters/butane n-Butane, isobutane, propane
Propane Propane and butanes
Nail/varnish remover Acetone and esters
Paints/paint thinners Butanone, esters, hexane, toluene, xylene
Paint stripper Dichloromethane, toluene
Surgical plaster/chewing gum removers Trichloroethylene
Typewriter correction fluid/ paint thinners 1,1,1-Trichloroethane

Table 2. Unique Clinical Effects of Several Volatile Substances

Chemical Unique Effects
Benzene Hepatorenal toxicity, leukemia
Toluene Muscle weakness, GI symptoms,
renal tubular acidosis
Hexane Stocking-glove peripheral neuropathy
Xylene Encephalopathy, hepatorenal toxicity
Carbon tetrachloride Sudden death, arrhythmias
Gasoline Organic lead encephalopathy
Nitrites Methemoglobinemia, hypotension
Nitrous oxide Vitamin B-12 deficiency, neuropathy

POSTMORTUM EXAMINATION:
EXTERNAL:
Skin
* Paint or stains on the face, hands, or clothing
* "Huffer rash" - Erythematous “frost bite” eruption on the face and
oral mucosa
* Thermal or chemical burns on face or hands
* Conjunctival injection
* Cyanosis (suspect methemoglobinemia)

INTERNAL:
* Oral/airway burns
* Frostbite injury of the airway is associated with chlorofluorocarbons found
in air conditioners

COLLECTION OF TOXICOLOGIC SAMPLES:
Laboratory:
* Serum chemistry: Analyses may include a standard 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. Hypoglycemia may be noted.
* Serum levels: Serum drug levels may be helpful if the specific chemical involved is known and if the laboratory has the ability to measure these levels

Specific lab tests may be indicated for the following volatiles:

* Methylene chloride: Check carboxyhemoglobin level, use 100%
nonrebreather oxygen
* Alkyl nitrites: Check serum methemoglobin levels. effect.
* Carbon tetrachloride: Consider hepatic injury and necrosis.

TISSUE AND FLUID SPECIMAN SAMPLING:

TISSUE OR FLUID SAMPLE
Brain 500 g. or whole organ after histologic sampling: frontal
lobes usually least import for neuropathologist
Liver 500 g. or whole organ after histologic sampling
Lung One lung or each lung separately after histologic
sampling
Kidneys Each kidney separately after histolgic sampling
Stomach Entire with contents or contents separately; vomitus
if available
Intestine Separately tied portions of intestinal tract with contents
Cerebrospinal fluid As much as can be withdrawn
Heart blood 100 ml with preservative and 100 ml without
preservative
Peripheral blood 30 ml. using anaerobic technique to avoid evaporation
of volatile substances
Bile All
Urine All
Muscle 200 g aliquots
Fat 200 g aliquots
Hair 10 g
Fingernails 10 g
Vitreous humor 2 to 3 ml from each eye

Note: Specimens should be refrigerated or frozen. Specific toxicologic analysis for inhalants typically requires a specialized reference laboratory.

CONCLUSION:
The determination of the extent and the scope of inhalant abuse will remain problematic without appropriate procedures and protocols to determine whether or not an inhalant death has occurred. These guidelines provide a framework for this to be done.

 

 


 

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