DISCUSSION
Butane is a low molecular weight aliphatic hydrocarbon and the principle propellant used in spray on deodorant since the elimination of chlorofluorocarbons. It is also the most commonly misused volatile solvent in the UK, and was the cause of 52% of the 64 known solvent related deaths in 2000. Of great concern is that 43% of these deaths occurred in young healthy subjects who were trying VSA for the first time. The majority of people who misuse solvents are aged between 12 and 17 years, with a peak around 15 years, although there are recorded cases of use among children as young as 7 years.
While there are multiple case reports of cardiac and trauma related deaths from VSA in Europe and the USA, neurological complications are less common, with only one previous report of butane associated acute encephalopathy, one of chronic cerebral atrophy (neurodevasation), and one of prolonged hemiparesis.
Cardiac arrhythmias and vagal stimulation leading to cardiac arrest, along with anoxia, oedema, and respiratory depression are the principal causes of death. By spraying butane directly into the throat, the jet of fluid can cool rapidly
to 220˚C by expansion, causing prolonged laryngospasm. ‘‘Sudden sniffing death syndrome’’, first described by Bass in 1970, is the commonest single cause of solvent related death, resulting in 55% of known fatal cases. The myocardium is hypersensitised to epinephrine by the inhaled hydrocarbon, so that any sudden stimulation or excitation of the user can result in arrhythmias brought on by intrinsic epinephrine release. This also explains the poor outcome of
attempted resuscitations during which more epinephrine is routinely administered. Edwards and Wenstone suggest the use of amiodarone over epinephrine in cardiac arrest where VSA is suspected.
The enormous number of household products open to misuse and the exclusion of VSA in most drug awareness programmes mean that eradication of solvent misuse is unlikely. Legislation such as The Intoxicating Substance Supply Act of 1985 and The Cigarette Lighter Refill Regulation Act of 1999 are difficult to enforce, with only 53 convictions since their introduction. The high prevalence and varied clinical presentation of volatile solvent misuse will continue to present a challenge to emergency physicians until the technical problems of developing a non-toxic solvent can be overcome.
