Ammonia Inhalants, A.K.A. "Smelling Salts"

[Bieber]

So. Ammonia inhalants. They're controversial, and I've heard everything from "never use them" to "hey, why not?" but I want to know what YOU guys think. For anyone who's not familiar with them, ammonia inhalants are little quarter-size pouches that you squeeze to release "aromatic spirits of ammonia" that irritates the nasal mucosa and stimulates the breathing reflex.

They're most commonly used in EMS on apparently unresponsive patients who are presumed to be playing possum, that is, to give a patient faking unresponsive a stimulant so unpleasant that they will react and no longer be much interested in faking unresponsiveness.

According to a 2006 article from the British Journal of Sports Medicine, there are no reports of injury as a result from ammonia inhalant use, and though ammonia is toxic, the amounts used in the inhalants are considered too low to result in toxicity. All the same, there is the risk of, say, stimulating a person who is spine boarded and causing them to jerk their head so hard that they exacerbate an existing spinal cord injury. To my knowledge, there hasn't ever been a case of this.

So, here's your chance to weigh in. Use them? Ever used them? Do you like 'em, hate 'em, think they're the best thing in the world, loathe their very existence?

[FireMedicChick164]

we don't carry them, don't use them, they aren't in protocol. The way I figure it, if a patient is faking being unconscious and is good enough at it to pass our "tests" (ie: the hand drop, scratching to bottom of their feet, etc.) then the hospital can deal with them because they are doing it for a reason (whether good or bad).

We actually had a female patient who was "unconscious" and had us fooled until we got to the hospital and the sat right up and talked to the nurses as soon as we were out of the room. Apparently there was an issue with her husband (unknown what it was) and she figured that was then only way for her to get out from under his watch and get some help. We even went as far as to cut off her dress in the rig looking for any reason she wasn't responsive! She didn't flinch at all.....even passed the hand drop test!!

[DwayneEMTP]

we don't carry them, don't use them, they aren't in protocol. The way I figure it, if a patient is faking being unconscious and is good enough at it to pass our "tests" (ie: the hand drop, scratching to bottom of their feet, etc.) then the hospital can deal with them because they are doing it for a reason (whether good or bad).

We actually had a female patient who was "unconscious" and had us fooled until we got to the hospital and the sat right up and talked to the nurses as soon as we were out of the room. Apparently there was an issue with her husband (unknown what it was) and she figured that was then only way for her to get out from under his watch and get some help. We even went as far as to cut off her dress in the rig looking for any reason she wasn't responsive! She didn't flinch at all.....even passed the hand drop test!!

Then you treat appropriately, right? What is the down side if you're wrong? I see increading numbers of people thinking that they're cool for 'catchin' those that are faking, but what's the upside if you're right? What's the downside if you're wrong? The upside is minor, bragging rights at best, the downside is a bruise to your paramedic soul, so do you find that to be a worthwhile cost/benefit? If so, then I think that you're shameful. Care for patients, care for people, but let the wankers brag about withholding care.

Just my thoughts..

Dwayne

[Bieber]

That's a good point, Dwayne. And hopefully, regardless of whether or not anyone or anyone's service is using ammonia inhalants nobody is withholding care from a patient that remains unresponsive following attempts to elicit a response. Unresponsiveness of unknown etiology is just that until it can be ruled out by either eliciting a faker to respond, or by field examination that indicates another cause.

[Richard B the EMT]

Ammonia Inhalants used to be required disposable stock on ambulances in New York State. I don't recall when the orders came from the state DoH to take them off the ambulances, but, if memory serves, it was because DoH presumed that if the patient fainted, the period from the actual fainting until they awakened was therapeutic, and should not be interrupted. Don't hold me to that interpretation.

[Lone Star]

I've never had occasion to use them. There are other methods we can utilize if we suspect that the patient is faking unconciousness, like scraping the bottom of the feet, brushing the eyelashes and the 'hand drop' tests.

I've heard stories from other crews about how they picked up a drunk during their shift and popped 3 or 4 of them into the NRB, and then laughed about how fast the patient 'came to'...

Yeah, we've got to do things that will cause discomfort and even pain, but to intentionally do it is abuse.

I've heard crew members talking about how they intentionally used the largest bore cath they had on a drunk, unlicensed pharmacist or the 'urban outdoorsman' just because they could. I find these practices appalling, and I'm utterly disgusted by those that feel the need to employ such tactics for their amusement!

[HERBIE1]

In many areas, for years "poppers" were almost a first line drug. Not saying it's right, but that's the way it used to be. Now, as was noted, "proving" someone is faking is a waste of time and is basically irrelevant. If they are going through all the trouble of feigning unresponsiveness, let the hospital deal with the drama. Whatever the reason for their act, it's nothing we will be able to "fix" in the brief period they are with us. Psychological issues, domestic problems- nothing we will be able to cure in a few minutes. Besides, in my book- quiet, compliant, and passive is far better than angry and combative.

I found that over time, many people even developed a tolerance to these things- they simply had no effect on them.

Now some of the justifications I heard for using them are so that we do not "overtreat" someone who has no serious medical issues, but if we check a blood glucose, maybe push Narcan, then what else will we do for someone who has stable vitals? Yes, there is a cost factor, but really, we cannot be concerned about that either.

If a person has a simple syncopal episode- from fear, emotional distress, pain, etc, then they will quickly wake up on their own anyway. Treat the underlying problem and transport.

[HEMSdaddy23]

Ammonia is one of those take it or leave it things. Can it hurt somebody, yes if they have a hyper-sensitivity to ammonia like some asthmatics. A drunk pt who is "unresponsive" can benefit from this lovely ammonia bullet though.

Have I used it, yes and will I use it again, yes. Personnally I dont like the possum players and would truly like to know if they are unresponsive and rule out OD.

just my thoughts, be safe

[Chief1C]

Oh? A drunk can benefit from it? You consider death, a benefit?

We all have at least one bad habit. It's a heritage trait which I choose to continue, not open to discussion. In July, I passed the point of no return to soberness. I was down and out, and could not be woken up. Although, I doubt they tried hard. Someone had the bright idea to wake me the 'old way'. It worked, except I awoke while vomiting. My mouth, out my nose, ruined my sense of smell for a couple days. Guinness. It was like one of these adjustable flow fire hose nozzles, you turn it all the way to the left, and it flushes. Could have very easily turned into a case of aspiration, drowning in my own mistakes, literally. Done the same thing plenty of times, and never had any problems, as long as nobody was forcing me back to the light of the moon.

[HEMSdaddy23]

Oh? A drunk can benefit from it? You consider death, a benefit?

Even a drunk who is passed out will snort at the smell of ammonia; and no I am not one of those who start a 14ga on every drunk either. Example - flew in to pick a pt up and on arrival ER doc frantic that pt needed to be intubated due to ETOH and AMS with possible HI. Ammonia cap and viola we had an alert pt who was A&O x 3, not doing a needless RSI on said pt. CT was negative PTA.