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

[DwayneEMTP]

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.

I hear what you're saying brother, and I dig your tag line! But as stated elsewhere, if you truly need to gauge responsiveness to r/o an OD, there are other ways to accomplish this. And is their level of responsiveness truly that important when considering the degree of drug/alcohol intoxication? I don't believe it is. There are significant physiological markers in this population of patients that should steer you down the correct path without resorting to ammonia.

Is it a terrible option? Not if used by an honest to God adult for the purposes of patient treatment. I just think that most often that is not the case. And I think it's lazy assessment. You sound like a smart man. Can you truly tell me that you don't know what response you'll get before you apply that particular intervention? Do you not have a really good idea what your pulse ox will say before you apply it? If not, then I'd argue that you have no right to be using it. Don't you most often know what your monitor is going to tell you before you read it? As before. And if your assessment skills are weak, or tired, or just simply not worth applying in the 'possibly drunk, possibly OD'd, possibly faking' crowd? Then I think that is a separate issue all together.

Of course I don't know you, and have only a few posts to judge you by, so I'll ask that you believe that my comments are meant for the purpose of debate and not to slander you personally. I'm grateful for your thoughts, and for the fact that you're brave enough to share them.

Dwayne

[CBEMT]

Our trauma center uses it all the time due to the number of drunks they get (don't ask). If the patient wakes up with a 'cap and stays awake, they don't get a "critical" room. No response, in they go. They also have an even more noxious stimulant if that doesn't work, something they pour onto a small stick and hold to the nose.

Me personally, it has no place in my care. You either respond to pain or you don't.

Our trauma center uses it all the time due to the number of drunks they get (don't ask). If the patient wakes up with a 'cap and stays awake, they don't get a "critical" room. No response, in they go. They also have an even more noxious stimulant if that doesn't work, something they pour onto a small stick and hold to the nose.

Me personally, it has no place in my care. You either respond to pain or you don't.

[HERBIE1]

Our trauma center uses it all the time due to the number of drunks they get (don't ask). If the patient wakes up with a 'cap and stays awake, they don't get a "critical" room. No response, in they go. They also have an even more noxious stimulant if that doesn't work, something they pour onto a small stick and hold to the nose.

Me personally, it has no place in my care. You either respond to pain or you don't.

Our trauma center uses it all the time due to the number of drunks they get (don't ask). If the patient wakes up with a 'cap and stays awake, they don't get a "critical" room. No response, in they go. They also have an even more noxious stimulant if that doesn't work, something they pour onto a small stick and hold to the nose.

Me personally, it has no place in my care. You either respond to pain or you don't.

Well, a trauma center is a different story. When I worked at a Level 1, they would also do similar techniques to quickly establish a baseline LOC. In a busy ER, with multiple critical traumas rolling in, needlessly tying up a critical bed and resources only harms patient care. In a slower ER, the staff may have more time to do hand holding and such, but the reality is, it's about triage and properly allocating resources. Like you mentioned, if you commit a lot of resources to a patient who may not need them, what happens when that critical, unstable trauma rolls in?

When I was in that realm, the trauma docs were also much quicker to RSI a combative patient then they would in an average ER setting. Why? Again- triage and time management. They could spend 30 minutes or more trying to calm and/or restrain a difficult patient and then be able to assess them, or they could gain control of the situation and quickly assess and treat them.

[HEMSdaddy23]

I hear what you're saying brother, and I dig your tag line! But as stated elsewhere, if you truly need to gauge responsiveness to r/o an OD, there are other ways to accomplish this. And is their level of responsiveness truly that important when considering the degree of drug/alcohol intoxication? I don't believe it is. There are significant physiological markers in this population of patients that should steer you down the correct path without resorting to ammonia.

Is it a terrible option? Not if used by an honest to God adult for the purposes of patient treatment. I just think that most often that is not the case. And I think it's lazy assessment. You sound like a smart man. Can you truly tell me that you don't know what response you'll get before you apply that particular intervention? Do you not have a really good idea what your pulse ox will say before you apply it? If not, then I'd argue that you have no right to be using it. Don't you most often know what your monitor is going to tell you before you read it? As before. And if your assessment skills are weak, or tired, or just simply not worth applying in the 'possibly drunk, possibly OD'd, possibly faking' crowd? Then I think that is a separate issue all together.

Of course I don't know you, and have only a few posts to judge you by, so I'll ask that you believe that my comments are meant for the purpose of debate and not to slander you personally. I'm grateful for your thoughts, and for the fact that you're brave enough to share them.

Dwayne

Dewayne,

Yes I believe the comments are for debate and that is why I posed them and posted because I knew ammonia is a VERY debated thing. Now I have been in the EMS field for 10 years and used it maybe 3 times. In the scenario I posted all vitals were WNL, CT negative, narcan already given and ETOH reaking. Yes I knew the pt would come around after getting the ammonia, it was a peace of mind thing for the sending ER physician who never heard of ammonia caps.

I like hearing other peoples opinion, respect each opinion and learn from some :-). Good post.

[spenac]

Surprises me when people still use such archaic methods to "catch" a "faker". Hand drop, why? If turns out your wrong you have done harm.

[Just Plain Ruff]

When I first started out in EMS I had a hard time differntiating from the fakers to the non. I used ammonia on a number of patients but my BS Detector got better and my assessment skills got better to the point where ammonia wasn't needed anymore.

I personally know a ER doc who dug several ammonia caps out of the nasal passages of a very drunk unconscious woman. In the end he said she had to have reconstructive surgery on her septum and nasal passages because of the ammonia burns and infections.

I think a quick use of ammonia for those who you think are faking is warranted and appropriate at times but if no response then treat appropriately.

That's the bottom line here, use your mind, your tools and your gut and treat appropriately and never ever delay treatment.

[Bieber]

Surprises me when people still use such archaic methods to "catch" a "faker". Hand drop, why? If turns out your wrong you have done harm.

The hand drop isn't very likely to hurt them, and even the ammonia inhalants have, at least according to the British Journal of Sports Medicine, never caused harm to any patients. Though I must ask, what "non-archaic" methods do you use to assess responsiveness? Is it just the painful response and corneal reflex or do you do something else to differentiate between the truly obtunded and those who are playing possum?

[CBEMT]

I've seen a local crew blow off a "faker" that "failed" the hand-drop test, but the triage nurse put the patient in a critical room anyway because she just had one of those feelings about it.

Patient turned out to have a head bleed.

Yeah, I know, anecdotal evidence isn't. But if anyone can prove it works with a high degree of specificity, feel free to point us in the right direction.

[Richard B the EMT]

In the scenario I posted all vitals were WNL, CT negative, narcan already given and ETOH reaking.

Minor tangent, if you don't mind (and even if you do...)

To quote most of my instructors, and several EMS related writers, please don't use the "WNL" phrasing, especially on your call reports. We know it is intended to mean "Within Normal Limits", but if used in a lawsuit, the lawyers always will try to tear you, your partner, and your agency down, by stating that it means "We Never Looked".

Back on topic, now

A crew from my Volunteer Ambulance Corps, circa 1975-ish, was on standby at a local High School (American) football game, when one of the team members from the other school took a hard "hit". As related to me, one of my colleagues dropped an ammonia inhalant (which had the nickname of a "snapper" as you snap them to activate the aroma) onto the guy, which caused him to react so violently, they had to get a ladder to get him off the ambulance roof. Seeing this, his team was demoralized, especially as the crew was cheering for the home team (most were graduates of the school), and was eventually beaten in the game.

[FireMedic65]

The only time I have ever seen them being used (besides tv/movies) was when I was donating blood. This was probably 10yrs ago when I witnessed them being used. My good friend was next to me donating.. and we thought it would be fun to see who could fill the bag the quickest. Needless to say, it was stupid and all that jazz.. but when we were both done we sat down to eat out juice and cookies. My friend started to get droopy and put his head down. A nurse came over (slowly) and asked what was wrong.. I said he was tired. She nudged him.. she said "go away" in a half sleepy like voice. The nurse called for the doctor to come over.. he cracked open an inhalant and put it under my friends nose. My friend immediately got up and punched the doctor in the face, then sat back down and put his head on the table again. When the principal asked why he punched him he said "I was tired.. and that asshole was shoving crap in my face."

Not really sure if this story pertains to the topic at hand... but for that reason.. I never used them.