Is ethyl chloride the new nitrous oxide? A case report.

BACKGROUND: Over the last decade, there has been an emerging trend of recreational misuse of several drugs and inhaled solvent including ethyl chloride. This case report follows CARE guidelines and highlights, with supporting video, the neurological features of ethyl chloride intoxication. CASE PRESENTATION: A 48-year-old man was seen for the sudden occurrence of an unsteady gait with dizziness. His only medical history was a chronic and treated HIV infection without any complications. Clinical examination revealed a cerebellar syndrome associated with impairment of short-term memory. Biological and radiological workups were normal. After several days, the patient recalled ethyl chloride inhalation. He fully recovered after being discharged from hospital. CONCLUSION: Clinicians should recognise the clinical features and neurological manifestations of ethyl chloride intoxication due to the potential fatal cardiovascular complications of this intoxication.

Reversible Neurotoxicity Due To Excessive Use of Ethyl Chloride.

BACKGROUND: Ethyl chloride is commercially available as a DVD/VCR cleaner, and can be found as a gasoline additive and topical anesthetic. There is an emerging trend of recreational huffing to enhance sexual relations. Neurotoxicity from repeated abuse is uncommon. CASE REPORT: A 36-year-old man with a history of intermittent ethyl chloride use for 15 years presented to the Emergency Department with an inability to walk for 4 days after frequent use for 1 week. The patient reported a rapid titration of inhalation from zero to eight cans of 4.6 oz ethyl chloride aerosol per day over a 1-week period. Initial vital signs were heart rate 88 beats/min, blood pressure 147/60 mm Hg, temperature 37.2°C (99°F), and respiratory rate 16 breaths/min. Physical examination was notable for slurred speech, ptosis, a wide-based and ataxic gait with short strides, inability to stand without support, loss of toe/finger proprioception, horizontal and vertical nystagmus, and dysmetria on coordination testing. Strength and sensation were preserved. His work-up included computed tomography and magnetic resonance imaging of the brain, cervical, thoracic, and lumbar spine that demonstrated no acute abnormalities. On hospital day 9, the patient was able to ambulate with mild difficulty. WHY SHOULD AN EMERGENY PHYSICIAN BE AWARE OF THIS?: Toxicity from excessive ethyl chloride huffing has been rarely reported. The toxicity was characterized with cerebellar findings, no attributable laboratory abnormalities, and no radiographic abnormalities on computed tomography/magnetic resonance imaging. The neurotoxicity resolved with supportive care. This case of excessive huffing of ethyl chloride presenting with neurotoxicity and ataxia further characterizes a rare complication of ethyl chloride toxicity that is gaining popularity.

Ethyl chloride spray, a local anesthetic in arterial blood gas sampling: A randomized, controlled, double-blinded study.

AIM: Arterial blood gas sampling provides useful information on respiratory parameters and acid-base balance. However, this procedure is painful and uncomfortable for the patient. Therefore, this study aimed to examine the analgesic efficacy of ethyl chloride spray compared to a placebo during radial artery blood gas sampling. METHOD: This randomized, double-blind, placebo-controlled study was conducted at the emergency department of a tertiary hospital. A total of 202 patients were randomly divided into two groups: ethyl chloride spray (n = 101) and placebo (n = 101). The analgesic efficacy of ethyl chloride spray was compared with the placebo using the Visual Analog Scale (VAS). RESULTS: The VAS score was determined to be 4 [interquartile range (IQR): 1.0] for the ethyl chloride spray group and 5 (IQR: 1.0) for the placebo group. The analgesic efficacy of ethyl chloride spray in reducing pain was statistically significantly higher compared to the placebo (p = 0.000). CONCLUSION: Ethyl chloride spray has analgesic efficacy in arterial blood gas sampling. Therefore, the use of this spray provides an analgesic effect on patients during arterial blood gas sampling performed in the emergency department.

Two Cases of Fatal Inhalation of Easily Available "Recreational" Substances.

ABSTRACT: We present 2 cases of fatal inhalation of easily available highly volatile substances that occurred in a recreational context. Case 1 concerns an 18-year-old man who was found dead with a 25-L plastic bag pulled over his head and a whipped cream steel siphon connected to the bag. The deceased was known to previously have inhaled nitrous oxide. Autopsy results were unremarkable, toxicological analysis using static headspace gas chromatography coupled to mass spectrometry analysis proved the presence of nitrous oxide in lung tissue and blood. Asphyxiation was ascertained as the cause of death. Case 2 describes the death of a 54-year-old man found dead on his bed wearing a rubber gas mask. A bottle with ethyl chloride-containing cold spray was found beside him. Autopsy did not reveal relevant pathological findings; a subsequent toxicological analysis proved the presence of ethyl chloride. Respiratory arrest because of ethyl chloride inhalation was established as the cause of death. The 2 cases presented here demonstrate the danger of easily available, volatile substances with a high potential for abuse. A careful investigation of the death scene, proper specimen collection during the autopsy, and extensive toxicological tests, including headspace gas chromatography coupled to mass spectrometry analysis, are necessary to prove inhalation of these substances.

Inhalant Abuse of Ethyl Chloride Spray: A Case Report.

Ethyl chloride spray, which is usually used to relieve pain after injuries, is increasingly being used as a sniffing alternative. The number of people using this is rising due to its easy availability, cost-effectiveness and legality. The high lipid solubility of ethyl chloride leads to a rapid absorption of it in the lungs. However, data on the biotransformation of ethyl chloride in humans are sparse. We present the case of a 53-year-old male who had been inhaling ethyl chloride up to 3 times a week since 25 years, and describe his symptoms and the circumstances of abuse. This should help raise awareness of this issue so that abuse can be recognized early and rapid action taken.

Comparison of the Effects of Vapocoolant Spray and Topical Anesthetic Cream on Pain During Intraarticular Injection of the Shoulder: A Randomized Double-Blind Controlled Trial.

OBJECTIVE: This study was performed to compare the effects of a vapocoolant spray and a eutectic mixture of local anesthetics (EMLA) cream on reducing pain during intra-articular (IA) injection of the shoulder. DESIGN: Double-blind randomized placebo-controlled clinical trial. SETTING: University hospital. PARTICIPANTS: Patients (N=63) who underwent IA injection of the shoulder joint were randomized into the spray group, EMLA group, or placebo group. INTERVENTION: Placebo cream+vapocoolant spray (spray group), EMLA cream+placebo spray (EMLA group), or placebo cream+placebo spray (placebo group) before IA injection. MAIN OUTCOME MEASURES: A 100-mm visual analog scale (VAS) for injection pain and 5-point Likert scales for participant satisfaction and preference for repeated use were administered immediately after IA injection. RESULTS: The VAS scores for pain during IA injection were 30.0 (95% CI, 19.7-41.2) in the spray group, 50.0 (95% CI, 37.7-63.0) in the EMLA group, and 53.8 (95% CI, 41.6-65.0) in the placebo group (F=6.403, P<.01). The spray group showed significantly better Likert scale scores than the placebo group for participant satisfaction (P=.003) and preference for repeated use (P<.001). CONCLUSIONS: Vapocoolant spray was effective in reducing pain during IA injection of the shoulder.

Reductive dechlorination of 1,2-dichloroethane in the presence of chloroethenes and 1,2-dichloropropane as co-contaminants.

1,2-Dichloroethane (1,2-DCA) is one of the most abundant manmade chlorinated organic contaminants in the world. Reductive dechlorination of 1,2-DCA by organohalide-respiring bacteria (OHRB) can be impacted by other chlorinated contaminants such as chloroethenes and chloropropanes that can co-exist with 1,2-DCA at contaminated sites. The aim of this study was to evaluate the effect of chloroethenes and 1,2-dichloropropane (1,2-DCP) on 1,2-DCA dechlorination using sediment cultures enriched with 1,2-DCA as the sole chlorinated compound (EA culture) or with 1,2-DCA and tetrachloroethene (PCE) (EB culture), and to model dechlorination kinetics. Both cultures contained Dehalococcoides as most predominated OHRB, and Dehalogenimonas and Geobacter as other known OHRB. In sediment-free enrichments obtained from the EA and EB cultures, dechlorination of 1,2-DCA was inhibited in the presence of the same concentrations of either PCE, vinyl chloride (VC), or 1,2-DCP; however, concurrent dechlorination of dual chlorinated compounds was achieved. In contrast, 1,2-DCA dechlorination completely ceased in the presence of cis-dichloroethene (cDCE) and only occurred after cDCE was fully dechlorinated. In turn, 1,2-DCA did not affect dechlorination of PCE, cDCE, VC, and 1,2-DCP. In sediment-free enrichments obtained from the EA culture, Dehalogenimonas 16S rRNA gene copy numbers decreased 1-3 orders of magnitude likely due to an inhibitory effect of chloroethenes. Dechlorination with and without competitive inhibition fit Michaelis-Menten kinetics and confirmed the inhibitory effect of chloroethenes and 1,2-DCP on 1,2-DCA dechlorination. This study reinforces that the type of chlorinated substrate drives the selection of specific OHRB, and indicates that removal of chloroethenes and in particular cDCE might be necessary before effective removal of 1,2-DCA at sites contaminated with mixed chlorinated solvents.

Enantioselective Synthesis of the Ethyl Analog of the Marine Alkaloid Haliclorensin C.

The enantioselective synthesis (3.7% overall yield in nine steps from 2) and biological screening of the ethyl analog of the macrocyclic marine alkaloid haliclorensin C (compound 5) are reported. Amino alcohol 3, generated by a LiNH2BH3-promoted reductive ring-opening/debenzylation sequence from phenylglycinol-derived lactam 2, was used as the starting chiral linear building block. Incorporation of the undecene chain via the nosyl derivative 12, methylenation of the pentanol moiety, and a ring-closing metathesis are the key steps of the synthesis.

Ethyl chloride spray for musculoskeletal ultrasound-guided injections: An alternative to subcutaneous injection of local anesthetic solution.

Ultrasound-guided injections such as steroid injections are common procedures involving the musculoskeletal system. They are usually performed after a subcutaneous injection of local anesthetic (LA), which can be painful. In 126 consecutive patients, local anesthesia was performed using ethyl chloride spray prior to a therapeutic ultrasound-guided injection in joints, tendons, or bursae. Ninety-nine (78.5%) patients found the use of ethyl chloride spray helpful. The use of ethyl chloride spray is an effective, patient-friendly alternative to the standard injection of local aesthetic for ultrasound-guided therapeutic musculoskeletal injections with the advantage of a lower cost of $0.18 per procedure.

Microbial reductive dehalogenation of trihalomethanes by a Dehalobacter-containing co-culture.

Trihalomethanes such as chloroform and bromoform, although well-known as a prominent class of disinfection by-products, are ubiquitously distributed in the environment due to widespread industrial usage in the past decades. Chloroform and bromoform are particularly concerning, of high concentrations detected and with long half-lives up to several hundred days in soils and groundwater. In this study, we report a Dehalobacter- and Desulfovibrio-containing co-culture that exhibits dehalogenation of chloroform (~0.61 mM) to dichloromethane and bromoform (~0.67 mM) to dibromomethane within 10-15 days. This co-culture was further found to dechlorinate 1,1,1-trichloroethane (1,1,1-TCA) (~0.65 mM) to 1,1-dichloroethane within 12 days. The Dehalobacter species present in this co-culture, designated Dehalobacter sp. THM1, was found to couple growth with dehalogenation of chloroform, bromoform, and 1,1,1-TCA. Strain THM1 harbors a newly identified reductive dehalogenase (RDase), ThmA, which catalyzes chloroform, bromoform, and 1,1,1-TCA dehalogenation. Additionally, based on the sequences of thmA and other identified chloroform RDase genes, ctrA, cfrA, and tmrA, a pair of chloroform RDase gene-specific primers were designed and successfully applied to investigate the chloroform dechlorinating potential of microbial communities. The comparative analysis of chloroform RDases with tetrachloroethene RDases suggests a possible approach in predicting the substrate specificity of uncharacterized RDases in the future.

Use and Effectiveness of Ethyl Chloride for Hand Injections.

PURPOSE: Limited literature supports using ethyl chloride topical spray as an anesthetic for hand injections whereas documented risks include frostbite, skin irritation, and inhalation toxicity. We hypothesize that ethyl chloride spray imparts no benefit to patients' perception of pain or anxiety for routine hand injections. METHODS: We first surveyed all members of the American Society for Surgery of the Hand to discern the prevalence of ethyl chloride use during routine injections. We then performed a prospective, randomized, study at 2 institutions evaluating the efficacy of ethyl chloride spray compared with "routine injection" (no topical spray) in patients indicated for a hand injection. All patients completed a pre- and postinjection 11-point questionnaire that inquired about various components of pain and anxiety. RESULTS: A total of 2,083 (73% response rate) American Society for Surgery of the Hand members responded to the survey and revealed that 59% of hand surgeons always or often use ethyl chloride, and 24% never use it. There were no differences for region or practice setting, but experienced surgeons were less likely to routinely use ethyl chloride (35%) compared with younger surgeons (66%). Among 151 patients participating in the clinical study (75 with ethyl chloride), there were no differences for any outcome measure assessed. Injection pain in the spray and no-spray groups, pain after 1 minute, and overall anxiety were equivalent. Subgroup analysis demonstrated no effect of sex, anticipated anxiety, or pain threshold. CONCLUSIONS: Ethyl chloride is widely used among hand surgeons but imparts no benefit for routine hand injections in the clinical setting. The potential risks and costs of ethyl chloride use may outweigh its benefits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Effects of ethyl chloride spray on early recovery after total knee arthroplasty: A prospective study.

BACKGROUND: Ethyl chloride spray as a common cooling modality has been widely used in acute sports injuries and joint injection procedures. Several clinical studies reported that use of ethyl chloride has positive effects on swelling, pain reduction and recovery from sports injuries. The main aim of present study was to analyze whether postoperative use of ethyl chloride spray benefits results after primary total knee arthroplasty (TKA). METHODS: Between April 1, 2014 and October 21, 2015, 306 subjects undergoing primary TKA used ethyl chloride spray for improving recovery from the damage from surgery. After exclusion of 31 subjects due to adverse events including periprosthetic joint infection (PJI), deep venous thrombosis (DVT), acute myocardial infarction, finally 275 subjects' data regarding pain score, knee range of motion (ROM), knee girth, time of being able to reach 90° knee flexion and analgesic consumption were analyzed. RESULTS: Significant differences in pain score, knee ROM at each time point and knee girth at on 21st and 28th postoperatively were detected without increased incidence of adverse events. Besides, time of being able to reach 90° knee flexion and analgesic consumption in the treatment group were significantly decreased in comparison to the control group. CONCLUSION: Use of ethyl chloride spray can help patients recovery from the damage from TKA safely.

Control of Vicinal Stereocenters through Nickel-Catalyzed Alkyl-Alkyl Cross-Coupling.

Vicinal stereocenters are found in many natural and unnatural compounds. Although metal-catalyzed cross-coupling reactions of unactivated alkyl electrophiles are emerging as a powerful tool in organic synthesis, there have been virtually no reports of processes that generate, much less control, vicinal stereocenters. In this investigation, we establish that a chiral nickel catalyst can mediate doubly stereoconvergent alkyl-alkyl cross-coupling, specifically, reactions of a racemic pyrrolidine-derived nucleophile with cyclic alkyl halides (as mixtures of stereoisomers) to produce vicinal stereocenters with very good stereoselectivity.

Overcoming the Challenges of Unstructured Data in Multisite, Electronic Medical Record-based Abstraction.

BACKGROUND: Unstructured data encountered during retrospective electronic medical record (EMR) abstraction has routinely been identified as challenging to reliably abstract, as these data are often recorded as free text, without limitations to format or structure. There is increased interest in reliably abstracting this type of data given its prominent role in care coordination and communication, yet limited methodological guidance exists. OBJECTIVES: As standard abstraction approaches resulted in substandard data reliability for unstructured data elements collected as part of a multisite, retrospective EMR study of hospital discharge communication quality, our goal was to develop, apply and examine the utility of a phase-based approach to reliably abstract unstructured data. This approach is examined using the specific example of discharge communication for warfarin management. RESEARCH DESIGN: We adopted a "fit-for-use" framework to guide the development and evaluation of abstraction methods using a 4-step, phase-based approach including (1) team building; (2) identification of challenges; (3) adaptation of abstraction methods; and (4) systematic data quality monitoring. MEASURES: Unstructured data elements were the focus of this study, including elements communicating steps in warfarin management (eg, warfarin initiation) and medical follow-up (eg, timeframe for follow-up). RESULTS: After implementation of the phase-based approach, interrater reliability for all unstructured data elements demonstrated κ's of ≥0.89-an average increase of +0.25 for each unstructured data element. CONCLUSIONS: As compared with standard abstraction methodologies, this phase-based approach was more time intensive, but did markedly increase abstraction reliability for unstructured data elements within multisite EMR documentation.

Topical ethyl chloride to reduce pain associated with venous catheterization: a randomized crossover trial.

OBJECTIVE: To compare pain associated with venous catheterization after administration of topical ethyl chloride vs placebo among emergency department health care providers. METHODS: We conducted a randomized, double-blind, placebo-controlled, crossover trial among a convenience sample of health care provider volunteers in a tertiary care urban emergency department. We randomly allocated subjects to initial treatment (ethyl chloride vs sterile water aerosol spray) and catheterization site (left or right antecubital fossa). After venous catheterization placement and discontinuation, subjects underwent a 5-minute washout period. All subjects then underwent venous catheterization in the contralateral antecubital fossa after administration of the alternative agent. We measured all outcomes after discontinuation of the second catheter. The primary outcome was difference in pain verbal numeric rating scale score (0-10) between the 2 agents. Secondary outcomes included preferred agent (binary) and future willingness to use agent on patients (5-point Likert scale). RESULTS: Thirty-eight health care providers were recruited; all completed the study. Median pain verbal numeric rating scale scores were 4 (interquartile range, 2-5) for placebo vs 2 (1-4) for ethyl chloride. The effect size for pain reduction with ethyl chloride compared with placebo was 2 (95% confidence interval, 0.5-2; P = .001). Most subjects (68.4%) preferred ethyl chloride to placebo. Five-point Likert scale scores measuring willingness to use preferred product on future patients were higher by 2 (95% confidence interval, 1-3) among subjects preferring ethyl chloride vs placebo. CONCLUSIONS: We found that topical ethyl chloride yields a greater reduction in pain associated with venous catheterization compared with topical placebo.

Enhanced photochemistry of ethyl chloride on Ag nanoparticles.

Enhanced photodecomposition of ethyl chloride (EC) adsorbed on SiO2/Si (100) supported silver nanoparticles (Ag NPs) under ultrahigh vacuum (UHV) conditions has been studied in order to assess the potential contribution of plasmonic effects. The cross section for photodecomposition of EC and overall photoyield were found to increase with increasing photon energy regardless of the plasmon resonant wavelength and with Ag coverage without any noticeable particle size effect. The influence of EC-Ag NPs separation distance on the rate of EC decomposition was studied in order to examine potential local electric field influence on the photodissociation process. Long (∼5 nm) photoactivity decay distance has been observed which excludes local surface plasmon dominance in the photodecomposition event. These findings suggest that the alignment of excited electron energy and adsorbate affinity levels is central for efficient photochemical reactions, whereas short-range electric field enhancement by plasmon excitation on top and at the immediate vicinity of silver nanoparticles does not have any measurable effect.