Nitrous Oxide Poisoning

Substance

Nitrous oxide

Common name or Trade name

一氧化二氮

笑氣

Involving system

-          Non-specific: dizzy. Headache. [1]

-          Consciousness: confusion, mental altered, coma. 

-          Liver: hepatitis [2]

-          Vit B 12 deficiency [1, 3 ,4, 5]

-          Nerve: myelopathy [2]

Presentation

-          Asphyxia when acute poisoning

-          Hypoxemia [6]

-          Myocardial infarcts, asystole.

-          Chest tightness. Cough, palpitation. [1]

-          ECG: myocardial ischemia.

-          MYELOPATHY [3, 5]

-          megaloblastic anemia, leukopenia, thrombocytopenia [1]

-          Death [1, 6]

-          Allergy: fever, chills, hives, wheezing, difficulty breathing

-          tingling or numbness in your fingers, toes, and limbs resulting from lacking Vit. B12 and anemia. [1]

-          high methylmalonyl CoA and homocysteine [4]

-          acute psychosis [4].

-          Slow NCV [1]

Antidote and Treatment

-          cause permanent neurological damage if not treated promptly

-          oxygen

-          intubate when respiratory failure. [1]

-          ACLS, CPCR if necessary / indicated. [1]

-          Avoid BZD/ sedative agent [1]

-          IVD or IM VitB12 1000μg/d* 5 days then per week 1000μg Vit B12 IM * 4-8 weeks [7].

Disposition  

-          Consult Neurology/ Toxicology /Poison Center.

- Follow-up at Neurology OPD and ever reported supplement time of Vit B12: two months.

References

[1]. 急性中毒救命術. 急診醫學會.三版.p.157—161.

[2]. Gullestrup A, Jensen RB, Bøgevig S, Nilsson PM. Ugeskr Laeger. 2019;181(20):V12180890.

[3]. Lin RJ, Chen HF, Chang YC, Su JJ. Subacute combined degeneration caused by nitrous oxide intoxication: case reports. Acta Neurol Taiwan. 2011;20(2):129-137.

[4]. Sethi NK, Mullin P, Torgovnick J, Capasso G. Nitrous oxide "whippit" abuse presenting with cobalamin responsive psychosis. J Med Toxicol. 2006;2(2):71-74. doi:10.1007/BF03161175

[5]. Lan SY, Kuo CY, Chou CC, et al. Recreational nitrous oxide abuse related subacute combined degeneration of the spinal cord in adolescents - A case series and literature review. Brain Dev. 2019;41(5):428-435. doi:10.1016/j.braindev.2018.12.003

[6]. Bäckström B, Johansson B, Eriksson A. Death from Nitrous Oxide. J Forensic Sci. 2015;60(6):1662-1665. doi:10.1111/1556-4029.12879

[7]. Pugliese RS, Slagle EJ, Oettinger GR, Neuburger KJ, Ambrose TM. Subacute combined degeneration of the spinal cord in a patient abusing nitrous oxide and self-medicating with cyanocobalamin. Am J Health Syst Pharm. 2015;72(11):952-957. doi:10.2146/ajhp140583

~~ June 18, 2020 Yu-Jang Su