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Fatal arrhythmia following deodorant inhalation
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Forensic Science, 5 (1975) 91-93 @ Elsevier Sequoia S.A., Lausanne - Printed in The Netherlands
CASE REPORT
FATAL
ARRHYTHMIA
FOLLOWING
DEODORANT
INHALATION
RICHARD C. KAMM Department of Pathology, in Shreveport, Shreveport,
Louisiana State University Louisiana (U.S.A.)
Medical Center, School of Medicine
SUMMARY With the removal from the general marketplace of volatile hydrocarbons which have been previously abused by “thrill-seekers”, new and often unlikely products are now being exploited by those who whish to escape reality. Many of these products have proven harmful. An example of such an u~cusual product is reported in this case of a sixteen-year-old male who inhaled Arrid Extra-Dry aerosol deodorant and subsequently died following ventricular fibrillation. The only findings at autopsy were cerebral edema, pulmonary edema and generalized visceral congestion.
INTRODUCTION
Before the early 1960’s the practice of hydrocarbon inhalation was practically unknown [ 11. The inhalation of volatile hydrocarbons is reported to have been first observed in California in the late 1950’s. The practice gradually spread eastward [ 2 3. Wyse [ 31 has divided the users of volatile hydrocarbons into two types: the chronic abuser who inhales volatile hydrocarbons on a regular basis and the “social” user who inhales them only occasionally. He points out that the mean age of subjects inhaling volatile hydrocarbons is between 14 and 15 years. Press and Done [ 41 have reported regular users who are as young as 7 or 8 years. The inhalation of volatile hydrocarbons is not limited to adolescents [ 5-71. Corliss [8] pointed out that subjects using volatile hydrocarbons are more likely to be male than female, noting that boys outnumbered girls by approximately 10 to 1. Before 1970 the general impression was that the user of volatile hydrocarbons died as a result of plastic bag suffocation. Bass [9] suggested that the mechanism of death is sensitization of the myocardium and the occurrence of sudden and severe arrhythmia. Kramer and Pierpaoli [lo] pointed out that the major constituent in aerosol deodorants is freon. The toxicity and abuse of freon has been well documented [ 11-131. Taylor and Harris [ 141 pointed out that freon is a fluoro-alkane chemically similar to halothane. The cardiovascular effects of halothane are well known [15] .
92
CASE REPORT
A 16-year-old Caucasian male reportedly sprayed Arrid Extra-Dry deodorant into a plastic bag and took several deep breaths from the bag. Two companions present at the time reported that he removed the bag from his face, grabbed one of them, said, “Help me!, help me!“, then collapsed. He was rushed to the emergency room of a local hospital where attempts at resuscitation were unsuccessful. An electrocardiogram performed in the emergency room revealed ventricular fibrillation. An autopsy was performed two hours after death. There was evidence of pulmonary edema. The left lung weighed 400 grams and the right weighed 450 grams. When the lungs were incised, watery fluid issued freely from the cut surfaces. There was also evidence of mild to moderate pulmonary vascular congestion. The heart weighed 300 grams. There was no evidence of cardiac dilatation or hypertrophy. There were no lesions of the myocardium, coronary arteries, or cardiac valves. The brain weighed 1430 grams. There was evidence of mild cerebral edema with minimal grooving of the medial surface of the uncus and mild cerebellar coning. The gyri were slightly flattened and the sulci narrowed. The remainder of the autopsy revealed only generalized visceral congestion. On microscopic examination the gross impression of pulmonary congestion and edema was confirmed. The myocardial architecture was intact. There was no evidence of myocardial necrosis, inflammation, hemorrhage or degeneration. Microscopic examination of the central nervous system confirmed the cerebral edema and mild vascular congestion. There was no evidence of necrosis, inflammation or hemorrhage. The other organs had microscopic evidence of vascular congestion. DISCUSSION
The usual technique of administration for inhalation of volatile hydrocarbons is to place a small amount of the substance to be used on a rag, piece of gauze or cloth which is then held over the mouth and/or nose during inhalation [3]. The most commonly used alternative method is to spray the aerosol into a bag or balloon, place the opening over the nose and mouth, and breathe deeply. A few deep breaths produce an effect which gradually dissipates over 30-45 minutes [6,16]. The initial effect is excitation of the central nervous system followed by severe central nervous system depression and unconsciousness [8,16]. Bass [9] reported 110 cases of sudden sniffing deaths without plastic bag suffocation. Volatile hydrocarbons most frequently involved were trichloromethane and fluorinated refrigerants. Severe cardiac arrhythmia resulting from light plane anesthesia and intensified by hypercapnia, stress, activity or a combination of these was considered the most likely explanation for sniffing death. Taylor and Hassis [14] pointed out that the most frequently abused hydrocarbon, toluene, has also been impli-
93
cated as a causative agent in cardiac arrhythmias. Cerebral edema following deliberate sniffing of volatile hydrocarbons has also been noted [ 171. In addition to freon, Arrid Extra-Dry contains aluminium phenylsulfonate which upon contact with the moist surface of the pulmonary tree may form phenol, sulfuric acid and alum. One would expect to find the corrosive effects of these agents in the respiratory tree of individuals who inhale these agents. However, such features were not seen in this present case, The pulmonary edema seen in this patient may be an early non-specific response to these agents or it may be a manifestation of the ventricular fibrillation produced by the volatile hydrocarbons.
REFERENCES 1 L.R. Kupperstein and R.M. Susman, A bibliography on the inhalation of glue fumes and other toxic vapors - a substance abuse practice among adolescents. Int. J. Addict., 3 (1968) 177-197. 2 H.H. Glaser and O.N. Massengale, Glue sniffing in children. The deliberate inhalation of vaporized plastic cement. J. Am. Med. Assoc., 181 (1962) 301-303. 3 D.G. Wyse, Deliberate inhalation of volatile hydrocarbons: a review. Can. Med. Assoc. J., 108 (1973) 71-74. 4 E. Press and A.K. Done, Solvent sniffing. Physiological effects and community control measures for intoxication from the intentional inhalation of organic solvents. Pediatrics, 39 (1967) 451-461. 5 J.W. Knox and J.R. Nelson, Permanent encephalopathy from toluene inhalation. New Eng. J. Med., 275 (1966) 1494-1496. 6 P.L. Man, Case report of paint thinner sniffer (enamel reducer). J. Kentucky Med. Assoc., 67 (1969) 195-197. 7 H.R. Clearfield, Hepatorenal toxicity from sniffing spot-remover (trichloroethylene). Am. J. Dig. Dis., 15 (1970) 851-856. 8 L.M. Corliss, A review of the evidence on glue sniffing - a persistent problem, J. Sch. Health, 35 (1965) 442-449. 9 M. Bass, Sudden sniffing death. J. Am. Med. Assoc., 212 (1970) 2075-2079. 10 R.A. Kramer and P. Pierpaoli, Hallucinogenic effects of propellant components of deodorant sprays. Pediatrics, 48 (1971) 322-323. 11 R.C. Downing, The toxicity of fluorinated hydrocarbon aerosol propellants. Aerosol Age, 5 (1960) 25. 12 J.W. Clayton, Fluorocarbon toxicity; past, present, future. J. Sot. Cosmet. Chem., 18 (1967) 33. 13 D. Lester and L. Greenberg, Acute and chronic toxicity of some hallucinogenative derivatives of ethane and methane. Ind. Hyg. Occup. Med., 2 (1950) 335. 14 G.J. Taylor and W.S. Harris, Cardiac toxicity of aerosol propellants. J. Am. Med. Assoc., 214 (1970) 81-85. 15 A.H. Goldberg, Cardiovascular function and halothane, in N.M. Green (Ed.), Halothane, F.A. Davis Co., Philadelphia, 1960, pp. 24-60. 16 J.L. Chapel and D.W. Taylor, Glue sniffing, Missouri Med., 65 (1968) 288-296. 17 C.L. Winek, W.D. Collom and C.H. Wecht, Fatal Benzene exposure by glue sniffing. Lancet, 1 (1967) 683.
Forensic Science, 5 (1975) 91-93 @ Elsevier Sequoia S.A., Lausanne - Printed in The Netherlands
CASE REPORT
FATAL
ARRHYTHMIA
FOLLOWING
DEODORANT
INHALATION
RICHARD C. KAMM Department of Pathology, in Shreveport, Shreveport,
Louisiana State University Louisiana (U.S.A.)
Medical Center, School of Medicine
SUMMARY With the removal from the general marketplace of volatile hydrocarbons which have been previously abused by “thrill-seekers”, new and often unlikely products are now being exploited by those who whish to escape reality. Many of these products have proven harmful. An example of such an u~cusual product is reported in this case of a sixteen-year-old male who inhaled Arrid Extra-Dry aerosol deodorant and subsequently died following ventricular fibrillation. The only findings at autopsy were cerebral edema, pulmonary edema and generalized visceral congestion.
INTRODUCTION
Before the early 1960’s the practice of hydrocarbon inhalation was practically unknown [ 11. The inhalation of volatile hydrocarbons is reported to have been first observed in California in the late 1950’s. The practice gradually spread eastward [ 2 3. Wyse [ 31 has divided the users of volatile hydrocarbons into two types: the chronic abuser who inhales volatile hydrocarbons on a regular basis and the “social” user who inhales them only occasionally. He points out that the mean age of subjects inhaling volatile hydrocarbons is between 14 and 15 years. Press and Done [ 41 have reported regular users who are as young as 7 or 8 years. The inhalation of volatile hydrocarbons is not limited to adolescents [ 5-71. Corliss [8] pointed out that subjects using volatile hydrocarbons are more likely to be male than female, noting that boys outnumbered girls by approximately 10 to 1. Before 1970 the general impression was that the user of volatile hydrocarbons died as a result of plastic bag suffocation. Bass [9] suggested that the mechanism of death is sensitization of the myocardium and the occurrence of sudden and severe arrhythmia. Kramer and Pierpaoli [lo] pointed out that the major constituent in aerosol deodorants is freon. The toxicity and abuse of freon has been well documented [ 11-131. Taylor and Harris [ 141 pointed out that freon is a fluoro-alkane chemically similar to halothane. The cardiovascular effects of halothane are well known [15] .
92
CASE REPORT
A 16-year-old Caucasian male reportedly sprayed Arrid Extra-Dry deodorant into a plastic bag and took several deep breaths from the bag. Two companions present at the time reported that he removed the bag from his face, grabbed one of them, said, “Help me!, help me!“, then collapsed. He was rushed to the emergency room of a local hospital where attempts at resuscitation were unsuccessful. An electrocardiogram performed in the emergency room revealed ventricular fibrillation. An autopsy was performed two hours after death. There was evidence of pulmonary edema. The left lung weighed 400 grams and the right weighed 450 grams. When the lungs were incised, watery fluid issued freely from the cut surfaces. There was also evidence of mild to moderate pulmonary vascular congestion. The heart weighed 300 grams. There was no evidence of cardiac dilatation or hypertrophy. There were no lesions of the myocardium, coronary arteries, or cardiac valves. The brain weighed 1430 grams. There was evidence of mild cerebral edema with minimal grooving of the medial surface of the uncus and mild cerebellar coning. The gyri were slightly flattened and the sulci narrowed. The remainder of the autopsy revealed only generalized visceral congestion. On microscopic examination the gross impression of pulmonary congestion and edema was confirmed. The myocardial architecture was intact. There was no evidence of myocardial necrosis, inflammation, hemorrhage or degeneration. Microscopic examination of the central nervous system confirmed the cerebral edema and mild vascular congestion. There was no evidence of necrosis, inflammation or hemorrhage. The other organs had microscopic evidence of vascular congestion. DISCUSSION
The usual technique of administration for inhalation of volatile hydrocarbons is to place a small amount of the substance to be used on a rag, piece of gauze or cloth which is then held over the mouth and/or nose during inhalation [3]. The most commonly used alternative method is to spray the aerosol into a bag or balloon, place the opening over the nose and mouth, and breathe deeply. A few deep breaths produce an effect which gradually dissipates over 30-45 minutes [6,16]. The initial effect is excitation of the central nervous system followed by severe central nervous system depression and unconsciousness [8,16]. Bass [9] reported 110 cases of sudden sniffing deaths without plastic bag suffocation. Volatile hydrocarbons most frequently involved were trichloromethane and fluorinated refrigerants. Severe cardiac arrhythmia resulting from light plane anesthesia and intensified by hypercapnia, stress, activity or a combination of these was considered the most likely explanation for sniffing death. Taylor and Hassis [14] pointed out that the most frequently abused hydrocarbon, toluene, has also been impli-
93
cated as a causative agent in cardiac arrhythmias. Cerebral edema following deliberate sniffing of volatile hydrocarbons has also been noted [ 171. In addition to freon, Arrid Extra-Dry contains aluminium phenylsulfonate which upon contact with the moist surface of the pulmonary tree may form phenol, sulfuric acid and alum. One would expect to find the corrosive effects of these agents in the respiratory tree of individuals who inhale these agents. However, such features were not seen in this present case, The pulmonary edema seen in this patient may be an early non-specific response to these agents or it may be a manifestation of the ventricular fibrillation produced by the volatile hydrocarbons.
REFERENCES 1 L.R. Kupperstein and R.M. Susman, A bibliography on the inhalation of glue fumes and other toxic vapors - a substance abuse practice among adolescents. Int. J. Addict., 3 (1968) 177-197. 2 H.H. Glaser and O.N. Massengale, Glue sniffing in children. The deliberate inhalation of vaporized plastic cement. J. Am. Med. Assoc., 181 (1962) 301-303. 3 D.G. Wyse, Deliberate inhalation of volatile hydrocarbons: a review. Can. Med. Assoc. J., 108 (1973) 71-74. 4 E. Press and A.K. Done, Solvent sniffing. Physiological effects and community control measures for intoxication from the intentional inhalation of organic solvents. Pediatrics, 39 (1967) 451-461. 5 J.W. Knox and J.R. Nelson, Permanent encephalopathy from toluene inhalation. New Eng. J. Med., 275 (1966) 1494-1496. 6 P.L. Man, Case report of paint thinner sniffer (enamel reducer). J. Kentucky Med. Assoc., 67 (1969) 195-197. 7 H.R. Clearfield, Hepatorenal toxicity from sniffing spot-remover (trichloroethylene). Am. J. Dig. Dis., 15 (1970) 851-856. 8 L.M. Corliss, A review of the evidence on glue sniffing - a persistent problem, J. Sch. Health, 35 (1965) 442-449. 9 M. Bass, Sudden sniffing death. J. Am. Med. Assoc., 212 (1970) 2075-2079. 10 R.A. Kramer and P. Pierpaoli, Hallucinogenic effects of propellant components of deodorant sprays. Pediatrics, 48 (1971) 322-323. 11 R.C. Downing, The toxicity of fluorinated hydrocarbon aerosol propellants. Aerosol Age, 5 (1960) 25. 12 J.W. Clayton, Fluorocarbon toxicity; past, present, future. J. Sot. Cosmet. Chem., 18 (1967) 33. 13 D. Lester and L. Greenberg, Acute and chronic toxicity of some hallucinogenative derivatives of ethane and methane. Ind. Hyg. Occup. Med., 2 (1950) 335. 14 G.J. Taylor and W.S. Harris, Cardiac toxicity of aerosol propellants. J. Am. Med. Assoc., 214 (1970) 81-85. 15 A.H. Goldberg, Cardiovascular function and halothane, in N.M. Green (Ed.), Halothane, F.A. Davis Co., Philadelphia, 1960, pp. 24-60. 16 J.L. Chapel and D.W. Taylor, Glue sniffing, Missouri Med., 65 (1968) 288-296. 17 C.L. Winek, W.D. Collom and C.H. Wecht, Fatal Benzene exposure by glue sniffing. Lancet, 1 (1967) 683.