Volatile Substance Abuse Nottingham Child Health

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					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   This guideline applies to all children and young people under the age
applies:                                           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
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
 Sniffing
 Bagging
 Snorting
 Huffing
 Tooting
 Buzzing

Damian Wood                                             Page 1 of 5                                            May 2007
Paediatric Clinical Guideline
Emergency 1.4 Volatile Substance Abuse

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.

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

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.

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

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

Damian Wood                                  Page 2 of 5                                May 2007
Paediatric Clinical Guideline
Emergency 1.4 Volatile Substance Abuse

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

 History of substance misuse
            o   How long for
            o   How often
            o   How obtained
            o   Effect on family, friends, social and school functioning
            o   Predisposing, precipitating and perpetuating factors
            o   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

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

Damian Wood                               Page 3 of 5                                 May 2007
Paediatric Clinical Guideline
Emergency 1.4 Volatile Substance Abuse

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

    o   Airway – potential for upper airway obstruction
    o   Breathing – potential for chemical pneumonitis, pulmonary oedema
    o   Circulation – potential arrhythmias
    o   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

  National Poisons Information Service                         TOXBASE
       24 hour poisons enquiries              

                                               Access available at all workstations in the
               0870 600 6266                           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
        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

Depending on the level of substance misuse and age options for further support:
   o School nurse
   o Adolescent Health Clinic – referral to Dr Damian Wood
   o Compass Young People’s Drug and Alcohol Team
               17 a Huntingdon Street
               NG1 3JH
               Tel: (0115) 847 0445
               Fax: (0115) 847 0448
   o Thorneywood CAMHS Substance Misuse Team
               Porchester Road
               NG3 6LF
               Tel: (0115) 8440515

Damian Wood                               Page 4 of 5                                  May 2007
Paediatric Clinical Guideline
Emergency 1.4 Volatile Substance Abuse



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 Wood                               Page 5 of 5                               May 2007