View source for Talk:Nitrous oxide toxicity

=== Recommendations for acute care settings ===
I had a conversation with a medical toxicologist at Oregon Poison Center regarding this. Dumping my notes here:
* From ED perspective, the biggest concern for NO misuse is transient hypotension which can lead to falls and dysrhythmia.
* If stable on arrival, minimal workup needed.
* If neuro symptoms (e.g. ataxia, neuromuscular weakness) with history of regular abuse, recommends consulting with local poison control for guidance.
* Labs:
** Again, recommend deferring to poison control's recommendations.
** Can be helpful if admitting, otherwise unclear who will follow up and be able to interpret results, as there aren't typically outpatient toxicology clinics to refer patients to.
** B12 - limited usefulness, as NO inactivates B12 but does not actually lower free B12 levels. (my opinion: may be some justification in patients at risk for B12 deficiency which could exacerbate danger of NO abuse)
** MMA and homocysteine - elevated levels of these are more reliable for indicating B12 deficiency, but neither are perfect. MMA may be an easier test to order because it's a routine screening test for methylmalonic acidemia in newborns.
* Treatment:
** As usual in toxicology, no randomized controlled trials to guide treatment protocols.
** Very low risk to start patients on B12 supplement if they are regular nitrous user, though unclear how helpful.
** (my opinion: patient education! Counsel them on risks of continued NO abuse and discuss harm reduction strategies. Many NO users are in theirs 20s, so try to help them establish with primary care for follow up if needed.)