Paediatric Clinical Guideline

Emergency 1.4 Volatile Substance Abuse

Short Title: / Volatile Substance Abuse
Full Title: / Guideline for the assessment and management of volatile substance abuse in children and young people
Date of production/Last revision: / April 2008
Explicit definition of patient group to which it applies: / This guideline applies to all children and young people under the age of 19 years.
Name of contact author / Dr Damian Wood
Consultant Paediatrician Ext 64041.
Revision Date / April 2011
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Volatile Substance (Inhalant) Abuse

Background

Volatile Substance Abuse (VSA) is deliberate inhalation of a volatile substance to achieve a change in mental state. It may involve the inhalation of glue, aerosol, gas fuels and another of other substances.

Inhalants are the drug of choice for 11-13 year olds and second only to cannabis for 14-15year olds. Half of all inhalant related deaths occur in the under 18s and there are between 60-80 deaths pa in the UK. VSA can cause sudden death and in 30% of deaths there is little evidence of previous VSA. Girls are just as likely to misuse inhalants as boys but deaths are more common in boys.

Inhalants are readily available, inexpensive or free and often legal to purchase. They provide a rapid high which rapidly dissipates. They are easy to conceal and preventing access may be difficult.

The most commonly abused inhalants are:

  • Butane and propane (lighter fuel, deodorants and hairsprays)
  • Tolulene (adhesives and glue)
  • Mixed hydrocarbons (petrol)
  • Trichloroetahnes (correction fluid and dry cleaning fluid)
  • Acetones and esters (nail varnish remover)
  • Butanone, Hexane and Xylene (paint strippers)

Commercial products often contain a mix of solvents and the range in which these abusable chemicals are to be found are extensive and available. Metabolism may be influenced by other chemicals or common substances eg, aspirin, alcohol, nicotine but little is known about the clinical significance.

Modes of Administration

As in any form of drug misuse there are a wide variety of terms which describe the mode of administration:

  • Sniffing
  • Bagging
  • Snorting
  • Huffing
  • Tooting
  • Buzzing

Butane lighter fuel – nozzle is clenched between the teeth and pressed to release the contents for inhalation. The jet of fluid at -40oC can cause:

  • Burns to the upper airway leading to oedema and upper airways obstruction
  • Vagal stimulation leading to bradycardia and cardiorespiratory arrest

There is also at risk of fire and explosion as it is a flammable liquid.

Other forms of aerosol can be inhaled via a bag or through water. Liquid adhesives are usually inhaled from bags and rebreathing increases the risk of hypercapnia and hypoxia. Heating of the liquid releases more vapour but increases the risk of fire and explosion. Petrol and paints can be inhaled directly from the container.

Effects

VSA commonly presents as acute intoxication or chronic abuse. There is no consistent physical withdrawal syndrome with no advantage in gradual cessation or indication to prescribe substitute drugs.

Solvents are inhaled in a variety of ways, the most common being straight from the container, which often contributes to difficulty controlling the dose. Toxicology is poorly understood but volatile chemicals are absorbed via the lungs and most are exhaled out in an unchanged form, although some are metabolised and excreted via the kidneys. Some lipophilic solvents are attracted to areas of fatty tissue, particularly the brain.

Acute Effects

The onset of effects is within seconds and peak blood levels occur within minutes. The recovery can be equally as rapid. There are four stages of development of acute symptoms which are dose dependent:

Excitatory / Early CNS Depression / Medium CNS Depression / Late CNS Depression
Euphoria
Excitation
Exhilaration
Dizziness
Hallucinations
Sneezing
Coughing
Excess salivation
Intolerance to light
Nausea/vomiting
Flushed skin
Bizarre behaviour / Confusion
Disorientation
Dullness
Loss of self control
Ringing or buzzing in the head
Blurred/double vision
Cramps
Headache
Pain insensitivity
Pallor / Drowsiness
Uncoordinated
Slurred speech
Depressed reflexes
Nystagmus / Loss of consciousness
Bizarre dreams
Epileptiform seizures
EEG changes
Cardiorespiratory arrest

Sudden Death

This can occur during the first or continued use of solvents during acute intoxication. Causes can be broadly classified as direct or indirect effects.

Direct

  • Butane - Cardiac arrhythmias/VF
  • Inhalation cold spray, sudden severe vaso-vagal inhibition

Indirect

  • Asphyxia (plastic bag over face)
  • Inhalation of vomit
  • Fire/Explosion from ignition
  • Trauma/Accidents from intoxication

Chronic

In general, there is scarcity of reliable information on long term damage but experimental and industrial toxicological research suggests that several of the commonly used substances can cause

  • CNS damage eg, declining memory, attention span, cerebellar dysfunction
  • Peripheral neuropathy
  • Hepatotoxicity especially halogenated hydrocarbons
  • Nephrotoxicity including renal tubular acidosis
  • Bone marrow depression especially benzene

Clinical Presentation

VSA can present with a wide range of clinical features including:

Cardiac
  • VF
  • Asystolic cardiac arrest
  • Myocardial infarction
Skin/Mucosa
  • Halitosis
  • Oral and nasal mucosal ulceration
  • Rash
  • Burns
  • Epistaxis
Gastrointestinal
  • Abdo pain
  • Diarrhoea
  • Weight loss
Metabolic
  • Renal tubular acidosis
Methaemoglobinameia / Neurological
  • Ataxia
  • Agitation
  • Tremor
  • Vertigo and tinnitus
  • Visual impairment
  • Dysarthria
  • Acute Confusion/paranoia
  • Headaches
  • Seizures
  • Coma
  • Peripheral neuropathy
  • Muscle weakness
  • Cerebral oedema
  • Hyperreflexia
Respiratory
  • Aspiration pneumonia
  • Chemical pneumonitis
  • Cough
  • Rhinitis
  • Pulmonary oedema

History

  • History of substance misuse
  • How long for
  • How often
  • How obtained
  • Effect on family, friends, social and school functioning
  • Predisposing, precipitating and perpetuating factors
  • Assess motivation to change behaviour
  • Establish is this experimental recreational or established substance misuse
  • HEADSSS assessment to identify co-morbidities
  • Identify supports in place – strengths and difficulties

Examination

Evidence of use

  • Smell
  • Actual substance
  • Erosions or inflammation of face, mucosae, hands
  • HR, RR and GCS
  • Examination to look for above signs

Investigations and Management

Resuscitation and Stabilisation

Quiet, calm environment to avoid overstimulation to avoid catecholamine surges which may precipitate arrhythmias. If the young person is disorientated and confused then this should resolve within 5-20mins if due to VSA

  • Airway – potential for upper airway obstruction
  • Breathing – potential for chemical pneumonitis, pulmonary oedema
  • Circulation – potential arrhythmias
  • Disability – potential reduced conscious level +/or encephalopathy and need for airway and seizure control

See advice on TOXBASE for specific inhalants or discuss with National Poison’s Information Service.

National Poisons Information Service
24 hour poisons enquiries / TOXBASE

0870 600 6266 / Access available at all workstations in the emergency department.
Departmental user name and password can be obtained from nurse in charge

Further investigations dependent on level of intoxication

Blood – FBC, U&E, LFT, BG

Blood toxicology requires a 2ml EDTA sample and must be discussed with the clinical chemist

Urine – Dipstick

Urine toxicology for solvents only must be discussed with the clinical chemist

CXR - aspiration

ECG/Cardiac rhythm leads (For 6 hours if butane inhaled)

Ongoing Management

Toxbase will provide information about the period of observation for specific agents

Discharge

Depending on the level of substance misuse and age options for further support:

  • School nurse
  • Adolescent Health Clinic – referral to Dr Damian Wood
  • Compass Young People’s Drug and Alcohol Team

17 a Huntingdon Street

Nottingham

NG1 3JH

Tel: (0115) 847 0445

Fax: (0115) 847 0448

  • Thorneywood CAMHS Substance Misuse Team

Porchester Road

Nottingham

NG3 6LF

Tel: (0115) 8440515

Resources

References

Harris D Volatile Substance Abuse. Arch Dis Child (Educ Prac Ed) 2006;91:ep93-100

“Out of sight….not out of mind.” Children, young people and volatile substance abuse. A framework for VSA 2005 Department of Health

Drug Misuse in Britain: National Audit of Drug Misuse Statistics

ISSD 1991

Volatile Substance Abuse: A Report by the Advisory Council on the Misuse of Drugs

HMSO 1995

Re-Solv: The Society for the Prevention of Solvent and Volatile Substance Abuse – Newsletters (1998-1999)

Drug Misuse and Dependence: Guidelines on Clinical Management

HMSO 1991

Damian WoodPage 1 of 5May 2007