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

[Richard B the EMT]

If you don't respond to the first inhalant then you are too out of it to not go to the ER so your butt is on my gurney and on the way to the hospital.

Sounds good to me. Implied consent that the patient wants to go, and whatever else you do, the diesel bolus is always a good activity.

[HERBIE1]

Sounds good to me. Implied consent that the patient wants to go, and whatever else you do, the diesel bolus is always a good activity.

Agreed. What is the point of "proving" someone is faking it? All they need to do is complain of some vague, nonspecific problem and they need to be evaluated anyway.

Folks spend way too much time worrying whether a call is legit or not. We all know that a significant portion of our workload is BS(some areas more than others)-it's just part of the game.

[Bieber]

Agreed. What is the point of "proving" someone is faking it? All they need to do is complain of some vague, nonspecific problem and they need to be evaluated anyway.

Folks spend way too much time worrying whether a call is legit or not. We all know that a significant portion of our workload is BS(some areas more than others)-it's just part of the game.

Well, after four pages of some very interesting discussion, I think I'll finally weigh in on my own topic!

Your friendly disclaimer, as always (or at least till December), I'm just a student (so you already know half of what I say is wrong, haha), and my opinion is always up to revision, but here it is for what it's worth. First of all, yes, I use ammonia inhalants. Second of all, your question of "what is the point of proving someone is faking it?" I think is really at the heart of this issue, so I'm going to respond to that with my views, such as they are.

For me, I believe it's absolutely vital to know whether or not a patient is truly alert and oriented and simply non-compliant with the assessment versus truly unresponsive. After all, the level of alertness is right there next to airway in the ABCs. I don't need to tell anyone here that an unresponsive patient is a serious problem, and one that needs to be corrected or attempted to be corrected immediately. So if I have a patient that is truly obtunded, that is a serious pucker factor for me, and tells me that something has gone seriously wrong and needs to be corrected immediately to prevent them from getting any worse. And I am personally going to HAVE a line established on ALL unresponsive patients anyway I can get it, because regardless of what a person's vital signs are, if they are truly unresponsive then we're already behind the ball and I'm not going to be without a means to give them fluid or medications when the rest of their body catches up.

Now maybe I'll be able to get an IV, but maybe I won't. Do I really want to do an IO on an unresponsive patient with stable vital signs if I can't get IV access any other way? Well, I don't have too much of a problem with that. Like I said, if something has gone that wrong inside a person's body that they're unresponsive, it's only a question of time until it starts wreaking havoc on other body systems as well. I NEED to have venous access. But do I really want to start an IO on someone who's perfectly fine and just fibbing with me? Hell no. And you know what? Most of the time I'll be able to get venous access with an IV. But if I can't, and they don't really NEED the IO, well, I don't think there's much benefit to the significant risk that accompanies having a needle drilled into their bone. To help direct MY care, I need to know what I'm up against.

The other facet of this is how we direct the hospital's care. And I don't know how it works in your guys' system, but here a code red (I think most of the country calls them code III?) unresponsive patient is automatically limited in the number of hospitals they can be taken to. Which is no big deal. However, what IS a big deal is whether or not I'll be dragging away a doctor and a code team from patients who may truly need them not to mention automatically freeing up a portable x-ray and a CT for someone who doesn't need them. Now, I have no problem erring on the side of caution if there's any doubt in my mind, but I'm also not about to expect the folks at the hospital to pull themselves away from folks who may actually need them because I don't want to investigate the matter a little deeper and really find out, for myself AND for them, what we're up against.

I don't think highly of those people who decide to shove any amount of inhalants up a patient's nose, but I don't think it's inappropriate to hold one under their nose and pop it to see if that'll elicit a response. As providers, we need to know our patients' status, including their mental status, to help direct our own care, and also to direct the care they get at the hospital.

[Timmy]

So… I’ve missed this thread but to be truthful I’ve never actually heard or seen Ammonia Inhalants used, certainly not current practise in Australia (either that or I’m living under a rock). To me, if you mention Ammonia it’s tripping alarm bells and the ‘holly crap’ factor from my HAZMAT course, it’s not uncommon for an orchard cool room were I live to have an Ammonia leak which is quiet bad news (BA, splash suits, decontamination areas ect). But obviously there are different chemical compounds and consecrations if you guys are using these chemicals on unresponsive patients.

To be truthful I really can’t recall seeing any patients ‘fake’ unresponsiveness. At work were pretty aggressive with treating unresponsive patients, it’s not uncommon for 5 or so people coming at you with shears, airway management gear (OPAs, LMAs, ETTs), bag valve masks, suction, monitor dots, sticking for blood glucose, getting a line in, getting bloods, catheterising ect… If you have a GCS of 3, to 8 all this would be done within 5 to 10 minutes and we’d probably have you on the way to medical imaging or surgery depending on diagnosis or what ever track further investigations are heading. I’d guess we’d soon know if you were faking or not.

[Richard B the EMT]

So… I've missed this thread but to be truthful I've never actually heard or seen Ammonia Inhalants used, certainly not current practise in Australia (either that or I'm living under a rock).

Ammonia inhalants were, when allowed in New York State, inch long by 1/4 inch wide glass tubes, in thick cotton coverings, containing a small amount of spirits of ammonia. When used, we would snap them (hence my previous mention of calling them "snappers"), breaking the glass (the reason for the thick cloth coverings), and wave them in close proximity to the patient's nose.

Someone on this string mentioned seeing them actually inserted into the nostrils. When we were allowed them, this would have constituted malpractice. If someone had them so used on them, and they snorted in response, now you have an airway obstruction in the nasal cavities. I would not want to explain that one to an OLMC doctor, or the courts, later on.

And, Timmy, while you may be late to this particular dance, at least you made it here.

[HERBIE1]

Well, after four pages of some very interesting discussion, I think I'll finally weigh in on my own topic!

Your friendly disclaimer, as always (or at least till December), I'm just a student (so you already know half of what I say is wrong, haha), and my opinion is always up to revision, but here it is for what it's worth. First of all, yes, I use ammonia inhalants. Second of all, your question of "what is the point of proving someone is faking it?" I think is really at the heart of this issue, so I'm going to respond to that with my views, such as they are.

For me, I believe it's absolutely vital to know whether or not a patient is truly alert and oriented and simply non-compliant with the assessment versus truly unresponsive. After all, the level of alertness is right there next to airway in the ABCs. I don't need to tell anyone here that an unresponsive patient is a serious problem, and one that needs to be corrected or attempted to be corrected immediately. So if I have a patient that is truly obtunded, that is a serious pucker factor for me, and tells me that something has gone seriously wrong and needs to be corrected immediately to prevent them from getting any worse. And I am personally going to HAVE a line established on ALL unresponsive patients anyway I can get it, because regardless of what a person's vital signs are, if they are truly unresponsive then we're already behind the ball and I'm not going to be without a means to give them fluid or medications when the rest of their body catches up.

Student or not, your opinion is just as valid as anyone else's. Don't ever be afraid to express it.

Again, LOC is merely one of multiple S&S's, vitals, assessments that we check. It's also pretty easy to check if a person is "faking it" or they truly have a diminished LOC. Pupils, relfexes, neurochecks- plenty of ways to determine if your patient's mental status is truly depressed. You also need to consider the age and environment you find your patient. A 20 something, found "unresponsive" in the bathroom of a nightclub- well, it doesn't take a rocket scientist to suspect you may be dealing with alcohol or drug issues. An "unresponsive" 20 something at home, with a group of peers, and you find out your patient was fighting with her boyfriend- well, chances are you are dealing with an anxiety/drama type situation, and alerting the critical care team may not be my first priority. Does it mean you do not rule out more serious problems- of course not, but your index of suspicion changes based on where you find your patient.

If you find a 70 year old "unresponsive", chances are the person has real medical issues that may have caused the change in your patient. Would you immediately consider using an ammonia inhalant on such a patient? Of course not. Time, place, circumstances, age- all the result of an appropriate history and observation of the scene and they should help to dictate your care.

Now maybe I'll be able to get an IV, but maybe I won't. Do I really want to do an IO on an unresponsive patient with stable vital signs if I can't get IV access any other way? Well, I don't have too much of a problem with that. Like I said, if something has gone that wrong inside a person's body that they're unresponsive, it's only a question of time until it starts wreaking havoc on other body systems as well. I NEED to have venous access. But do I really want to start an IO on someone who's perfectly fine and just fibbing with me? Hell no. And you know what? Most of the time I'll be able to get venous access with an IV. But if I can't, and they don't really NEED the IO, well, I don't think there's much benefit to the significant risk that accompanies having a needle drilled into their bone. To help direct MY care, I need to know what I'm up against.

Good to be proactive and aggressive when treating patients, but don't always look for zebras. You have to put the whole picture together- based on your history, the scene, bystander information, assessments and any tools we have. In the vast majority of cases, these things will paint a pretty accurate picture of what's going on with your patient. If it looks like a duck, walks like a duck, and quacks like a duck...

The other facet of this is how we direct the hospital's care. And I don't know how it works in your guys' system, but here a code red (I think most of the country calls them code III?) unresponsive patient is automatically limited in the number of hospitals they can be taken to. Which is no big deal. However, what IS a big deal is whether or not I'll be dragging away a doctor and a code team from patients who may truly need them not to mention automatically freeing up a portable x-ray and a CT for someone who doesn't need them. Now, I have no problem erring on the side of caution if there's any doubt in my mind, but I'm also not about to expect the folks at the hospital to pull themselves away from folks who may actually need them because I don't want to investigate the matter a little deeper and really find out, for myself AND for them, what we're up against.

I agree that you may be in a situation where you have a choice of a small, community ER vs a larger, comprehensive hospital and your assessments will determine what level of care a person receives, then at that point, leave it up to medical control. Present your case, paint a thorough and detailed picture- especially if you are unsure as to what is going on- and let medical control dictate where the patient goes. Yes, ultimately you do what's best for your patient, but there is also a limit on the amount and type of information we can gather. Often times the subjective information you provide is crucial in determining the proper course of action once the patient arrives at the ER. The docs have the training and plenty of tools, but they have no idea the surroundings their patient came from, what was going on, the bystanders, the demeanor of witnesses, their statements, etc. That is your job to relate those details to them when pertinent.

I don't think highly of those people who decide to shove any amount of inhalants up a patient's nose, but I don't think it's inappropriate to hold one under their nose and pop it to see if that'll elicit a response. As providers, we need to know our patients' status, including their mental status, to help direct our own care, and also to direct the care they get at the hospital.

Dangerous thing to do sometimes. If you have a patient- maybe they have serious psych problems, are very angry at a significant other, etc, and after they take a sniff of ammonia, they can "wake up" swinging at you. Now you have an angry, abusive, and violent patient on your hands who still has whatever issues that made them become "unconscious". Whatever their issues are, chances are you will not be fixing them any time soon. Maybe the just want to get out of some situation, maybe they want to escape some personal problems. They often feel that is they present themselves as "seriously ill"- ie as being unconscious- they can ensure they will be removed from some real or perceived threat and someone will take them seriously.

We may have no idea why a person is feigning being unconscious, but even if it's a momentary escape from their world, this is what they want. It's not up to us to decide whether their reasons are worthy of a transport and/or hospital visit.

I used to have regulars who would be oblivious to needle sticks, arm drops, ammonia, noxious stimuli- the works, and we KNEW there was nothing seriously wrong with them. Often times they just wanted a warm bed and a meal. Chronic ETOH abusers, homeless- you would be surprised at how tough some folks are. They know the drill, the know how to play the game, and will do whatever they need to just to get what they want.

Everyone comes up with their own program, and with experience and time you will determine your own path. Sometimes simply playing detective and asking the right questions of bystanders, family, or even the patient can give you far more information than any exam or treatment we can provide.

After you do this for awhile and develop a relationship with your local ER's, other things also come into play. You will see- especially in the case of busy urban systems- that as simple as dropping an IV into someone changes how an ER must handle that patient. Some places require any patient with an IV to have a bed. An example- years ago when we first began administering nebulized albuterol, our protocols dictated that we start an IV, put them on the monitor- the full ALS work up. In the area I worked, we could have literally a dozen asthma cases in a day. Now multiply that by other rigs, plus walk-ins, and an ER could easily become overloaded. A couple ER's asked us to NOT start IV's on simple, stable asthma patients who were mild, maybe with some wheezing, with good sats and vitals. This way they could put them in a chair VS a bed, keep an eye on them, put them on a portable O2 sat machine, and give them more albuterol. Against protocol- maybe, but once they trusted you, they would ask if the person could sit in a chair vs needlessly tying up a bed. They also trusted us to say- "No, this person is pretty sick, I would keep an eye on them", and they would find an available bed for them. Eventually our protocols relaxed and full ALS was only required if the person was decompensating .

Now I am not advising you to violate your protocols,(well, in a way I am, I guess), but I think you understand what I'm saying here. Yes, sometimes we are required to do things we KNOW are not necessary because we are limited by our training and scope of practice. But- like most of medicine, nothing is simply black and white, and being a good provider is about seeing those grey areas and making reasonable adaptations as much as possible. We are all in this together, and speaking as someone who also worked in a busy Level 1 trauma center for years, in order for the system to work as smooth as possible, to be effective and provide the best care for the most people, we need to consider both sides of the equation, and the impact of what we do.

[Fox800]

I've found ammonia inhalants to be a safe and effective tool for determining responsiveness when used appropriately. Intentional misuse should be grounds for serious disciplinary action/termination (crap like dropping them in a nonrebreather and putting the mask over their face, putting them in the pt.'s nostrils, putting them in a syringe and depressing the plunger to shoot fumes up their nose, etc.) If I ever see someone doing that, there's going to be a come to Jesus moment ricky-tick.

My typical continuum of testing to establish responsiveness:

Loud verbal > Painful stimuli (nailbed pressure, pinch trapezius, no sternal rubs) > Ammonia inhalant held next to nose > NPA/OPA (judgment call)...after that, they're likely to get an ET tube if I can't find something to do to wake them up (i.e. D50 or Naloxone).

[dominic22]

I have experienced smelling salts, as the patient. One day at the police academy we were doing physical training, I began to feel as if I was sick and having trouble breathing. My condition began to rapidly go down hill and luckily we had an EMT-B there who was training with us. They laid me down onto the floor and check my vital signs. It was hard for me to keep my eyes open, not as if I was slipping unconscious. I kept my eyes close because it was much easier for. I started to hyperventilate and so they moved me into a different room. They contacted the fire department and when the fire department arrived on scene I guess they though I was semi-conscious, fainting, or faking. Well they placed a smelling salt under my nose and I began to shake because of the feeling. They then put me on a NRB and I felt as if I was suffocating. Once we were finally inside of the medic they hooked me up the EKG and I was listening for the medic to read my HR and rhythm. He said "HR: 140; Sinus Tachy".

The smelling salt did it's job, however of course I was not a fan of it. I also was not faking so it bothers me to think that they may have believed that.

[crotchitymedic1986]

A student's opinion is totally irrelevant. Run 1 call before you have an opinion !

[DwayneEMTP]

A student's opinion is totally irrelevant. Run 1 call before you have an opinion !