?Who's the Boss is Not a Food!?

“Who Who’s s the Boss” Boss is
Not a Food!
Kyle Lamphier
Morning Report
June 12, 2006

Case:
11yo male comes to the ED with a chief
complaint of “cough cough” x 3-4 3 4 days
Evaluated in Triage:
VS: 36.8 PMH—denies
PMH denies
96 24 106/68 96%O2
Current meds—denies
meds denies
NKDA
35kg
Sent to Fast Track

HPI:
Quality of cough? Productive?
Varies with time of day?
Any sick contacts?
Fever?
URI sx? sx
H/o environmental allergies?
Exacerbating/Alleviating factors?
Seasonal component?

Past history:
PMH—uncomplicated PMH uncomplicated pregnancy/perinatal
pregnancy/ perinatal
course; denies previous admits
IMM UTD (by report), NKDA, no PMD, has been
taking OTC cough suppressant without effect
FamHx—no
FamHx no h/o cough, bronchitis, asthma,
seasonal allergies, TB
SocHx—LAHW SocHx LAHW mom, younger brother
(healthy), no smoking at home, no pets, no
dust/mice/cockroaches, 6 th grade, good
student
Anything else you can or should ask?

PEx
VS—as VS as per Triage, RR still low 20’s 20
GEN— GEN “Looks Looks good” good
PULM— PULM
WOB—no WOB no rtx, rtx,
no heavy breathing, unable to count
to 10 without taking breaths between numbers
Auscultation—minimal Auscultation minimal to no air movement in all
fields, more diminished at the bases, occassional
scattered wheezes throughout, coughs with deep
breathing
Rest—WNL Rest WNL (with one small exception that’s that s
discovered only later)

Now what?
Send to OBS
Put on monitor— monitor
HR 120s, pulse-ox pulse ox 91%
Nebs
PIV
What else might you do?

Further History:
Upon more specific questioning, Mom
says that he has a cough that comes on
maybe 2x/year associated with URIs. URIs.
It
lasts about a week and then goes away
on its own
SUMMARY:
11yo male with apparently new onset
cough/wheeze + and underlying h/o cough
associated with URIs

DDx: DDx:
many things can cause acute cough…. cough
Pulm— Pulm
Cough variant asthma
Foreign body
Post-nasal Post nasal drip
Environmental allergies
Other— Other
Meds
Psychogenic (acute on
chronic)
Chemical exposures
ID— ID
Bacterial Pneumonia
URI
Pertussis
TB
Viral pneumonitis
Atypical pneumonia
Fungal/parasitic process
GI— GI
GERD
Aspiration

Further evaluation:
CXR—increased
CXR increased perihilar markings,
hyperinflation, no focal opacities, no
other abnormalities
CBC—9.2/14.3/41.8/278 CBC 9.2/14.3/41.8/278 N35/B0/L51
BMP—141/3.2/104/20/17/0.8/109/9.0
BMP 141/3.2/104/20/17/0.8/109/9.0

Re-evaluation Re evaluation of the pt. after
1 hour of continuous nebs:
Auscultation—better Auscultation better air movement at apices,
still diminished at bases, more pronounced
wheezing, still coughs with deep breathing
WOB—RR WOB RR 25, still with some difficulty counting
to 10, otherwise “looks looks good” good
Pulse ox—93% ox 93%
RN—asks RN asks if he’s he s also a diabetic; she points out
a strange odor on his breath…
breath

The The Family Family Guy Guy
Lois: Lois:
It's geat they picked your
theme, but isn't it a little esoteric?
Peter: Peter:
Esoteric?
(Zoom in to the guys in Peter's
brain)
Guy1: Could it mean sexy?
Guy2: I think it's a science term.
Guy3: Guy3:
Fellas, Fellas,
fellas! fellas!
Esoteric
means delicious!
(back to the real world)
Peter: Peter:
Lois, "Who's the Boss" is
not a food.
Brian (the dog): dog) : Swing and a
miss.

“Who Who’s s the Boss” Boss is not a
food . . .
. . . Something you might expect to hear from
someone abusing chemical inhalants

Introduction
Volatile substances—hydrocarbons,
substances hydrocarbons,
substituted hydrocarbons, nitrites—that
nitrites that
produce effects via direct inhalation
Often the first drugs of abuse by children
and adolescents because they are
inexpensive, hard to detect, and easily
obtainable

Epidemiology
Data from 2003 Youth Risk Behavior Surveillance
Survey (YRBSS) shows that 12% of students have
used inhalants during their lifetime, and that 4% were
using them currently (within the last 30 days)
Data from Poison Control Centers shows that ¾ of
users were male
Other user characteristics: lower perceived self-worth, self worth,
lower SES, comorbidities with conduct disorders and
drug/ETOH dependence

Techniques
Sniffing—container
Sniffing container
with an inhalant held
to nose
Huffing—a Huffing a cloth
saturated with an
inhalant held over
nose and mouth
Bagging—a Bagging a bag
containing an
inhalant held to nose
and mouth

Mechanism of Action
Enter blood stream through the lungs and
diffuse throughout body; highly lipid soluble— soluble
neurons very susceptible
Effects take place within seconds and can last
up to 45 minutes; intoxication maintained
through repeated use
Metabolism—depending Metabolism depending on the substance
inhaled, can be excreted through the lungs,
liver, and/or kidneys

Clinical manifestations
Clues to use—chemical use chemical odors on breath,
chemical stains on face or clothing,
empty solvent containers, used bags or
rags
Euphoria—inhalants Euphoria inhalants are CNS
depressants; depressants;
initially cause intoxication
similar to ETOH or marijuana followed by
sleepiness, decreased RR and HR,
impaired judgment and coordination

Systemic Effects
Depends on the substance used . . .
Pulmonary
Hypoxia
Asphyxia (if bagging) bagging
Chemical pnuemonitis
Surfactant dysfunction
Pulmonary edema
RAD similar to asthma
CV
Dysrhythmias
Myocarditis
MI
Sensitization of myocardium to
catecholamines
Bradycardia
Tachycardia
Hypotension
CNS
Slurred speech
Ataxia
Disorientation
Headache
Hallucinations
Agitation or aggresivness
SZ
Peripheral neuropathies
Depression of respiratory centers
of the brain causing respiratory
arrest
GI
N/V
Hepatotoxicity
Renal
Metabolic acidosis (K+ wasting)
Calculi
glomerulonephritis

Potential Causes of Death
Asphyxia from bagging
Suffocation from bagging or from oxygen
displacement via inhaled substance
Choking on vomitus
Careless or dangerous behavior
“Sudden Sudden sniffing death” death
Thought to be caused by cardiac arrhythmia
from myocardium overly sensitized to
catecholamines

Evaluation
Again, depends on the inhalant . . .
EKG and cardiac monitoring
Pulse oximetry
Drug screen
CBC, CMP, UA
Methemoglobin levels if nitrites
suspected
BLL if gasoline suspected
CXR

Management
Largely supportive
Acute illness
Supplemental O2
If arrythmias present, be careful of using catecholamines due
to the sensitized myocardium
If methemoglobin, methemoglobin,
then high dose O2 or IV methylene blue
If lead toxicity, chelation therapy
Call Poison Control!
Clearance of the substance depends on its half-life half life and
how it’s it s metabolized
Chronic effects may be reversible once the pt.
becomes drug free

Long Term Management
Formal detoxification if indicated
Possible referral to a treatment center
No good data comparing which types of
treatment programs may be effective

Back to our pt . . .
It’s It s presumed that he may have had an underlying
component of undiagnosed cough-variant cough variant asthma that
in this case was triggered by inhalant abuse
Particular substance inhaled is unknown
He was asked in private whether or not he was abusing
inhalants, and he denied it
He was admitted for respiratory distress and treated for
his apparent asthma exacerbation. Of note, he did
appear to continue to respond to typical asthma
management
Social work was consulted, and he continued to deny
using inhalants
Upon discharge he was given a PMD appointment, and
it’s it s unknown whether or not he followed up

References
Endom, Endom,
EE., MD. Inhalant Abuse in Children and
Adolescents. UpToDate, UpToDate,
2006.
Dinwiddie, SH. Abuse of inhalants: A review.
Addiction 1994; 89:925.
Kurtzman, Kurtzman,
TL, Otsuka, Otsuka,
KIN, Wahl, RA. Inhalant abuse
by adolescents. J Adolesc Health. 2001; 28:170.
Grunbaum, Grunbaum,
JA, Kann, Kann,
L, Kinchen, Kinchen,
S. et al. Youth risk
behavior surveillance—United surveillance United States, 2003. MMWR
Surveill Summ 2004; 53:1.
Neumark, Neumark,
YD,Delva, YD,Delva,
J, Anthony, JC. The
epidemiology of adolescent inhalant drug involvement.
Arch Pediatr Adlosec Med 1998; 152:781.