Smelling salts
To reduce the effects from exposure to ammonia, it is important to wash eyes and skin as quickly as possible with large amounts of water.
The Facts About Ammonia
Note to reader: This fact sheet is intended to provide general awareness and education on a specific chemical agent. For information on preparedness and response (e.g., for first responders and emergency medical personnel), please refer to the following Department resources:
- Chemical Terrorism Preparedness and Response Card (PDF, 45KB, 7pg.)
- Chemical Terrorism Wall Chart (PDF, 97KB, 1pg.)
What is ammonia?
Ammonia is one of the most widely produced chemicals in the United States. In pure form, it is known as anhydrous ammonia. Ammonia is also produced in the human body and is commonly found in nature. It is essential in the body as a building block for making proteins and other complex molecules. In nature, ammonia occurs in soil from bacterial processes. It is also produced when plants, animals and animal wastes decay.
What are the properties of ammonia?
Ammonia is a colorless highly irritating gas with a sharp suffocating odor. It dissolves easily in water to form ammonium hydroxide solution which can cause irritation and burns. Ammonia gas is easily compressed and forms a clear, colorless liquid under pressure. It is usually shipped as a compressed liquid in steel cylinders. Ammonia is not highly flammable, but containers of ammonia may explode when exposed to high heat.
How is ammonia used?
About 80% of the ammonia produced in industry is used in agriculture as fertilizer. Ammonia is also used as a refrigerant gas, to purify water supplies, and in the manufacture of plastics, explosives, fabrics, pesticides, dyes and other chemicals. It is found in many household and industrial-strength cleaning solutions. Cleaning solutions for industrial use contain higher concentrations of ammonia and can quickly cause irritation and burns.
How can people be exposed to ammonia?
Most people are exposed to ammonia from breathing its gas or vapors. Since ammonia exists naturally and is also present in cleaning products, exposure may occur from these sources. The widespread use of ammonia on farms and in industrial and commercial locations means that exposure can also occur from an accidental release or from a deliberate terrorist attack.
Ammonia gas is lighter than air and will rise, so that generally it does not settle in low-lying areas. However, in the presence of moisture, ammonia can form vapors that are heavier than air. These vapors can spread along the ground or other low-lying areas.
How does ammonia act in the body?
When ammonia enters the body as a result of breathing, swallowing or skin contact, it reacts with water to produce ammonium hydroxide. This chemical is very corrosive and damages cells in the body on contact.
What are the specific signs and symptoms of ammonia poisoning?
Ammonia is corrosive. The severity of health effects depends on the route of exposure, the dose and the duration of exposure. Exposure to high concentrations of ammonia in air causes immediate burning of the eyes, nose, throat and respiratory tract and can result in blindness, lung damage or death. Inhalation of lower concentrations can cause coughing, and nose and throat irritation.
Swallowing ammonia can cause burns to the mouth, throat and stomach. Skin or eye contact with concentrated ammonia can also cause irritation and burns.
What can you do if you think you may have been exposed to a large release of ammonia?
If you have been exposed to a large release of ammonia such as from a tanker truck rollover or from a leaking tanker rail car, take the following steps:
- Quickly move away from the area where you think you were exposed. If the release was indoors, go outside.
- If you are near a release of ammonia, emergency coordinators may tell you to either evacuate the area or to “shelter in place.” To “shelter in place” means to remain indoors to avoid being exposed to the chemical. While indoors, shut and lock all doors and windows; turn off air conditioners, fans and heaters; and close fireplace dampers.
- For more information on evacuation during a chemical emergency, see Facts About Evacuation. For more information on sheltering in place during a chemical emergency, see Facts About Sheltering in Place.
- Place your clothing inside a plastic bag and seal the bag tightly.
- Do not handle the plastic bag, and wait for instructions on proper disposal.
- Disposing of your clothing in a sealed bag helps protect you and other people from any additional exposure.
- Store the bagged clothing in a secure location away from people, especially children.
- Remove and dispose of contact lenses.
- Wash eyeglasses with soap and water before wearing.
- Do not use bleach to remove ammonia from your skin.
How is ammonia poisoning treated?
To reduce the effects from exposure to ammonia, it is important to wash eyes and skin as quickly as possible with large amounts of water.
There is no antidote for ammonia poisoning, but ammonia’s effects can be treated, and most victims recover. People who experience serious signs and symptoms (such as severe or constant coughing, or burns in the throat) may need hospital care.
Will laboratory testing assist in making treatment decisions if someone has been exposed to ammonia?
Laboratory testing for ammonia exposure will not be useful in making emergency treatment decisions. There are tests that can detect ammonia in blood and urine. However, these tests cannot definitely determine if someone has been exposed to ammonia from an outside source because ammonia is also normally found in the body. A person exposed to harmful amounts of ammonia will notice it immediately because of the strong, unpleasant smell; strong taste; and likely irritation to the skin, eyes, nose and throat.
How can I get more information about ammonia?
Call the following numbers, or visit the websites listed among the “Sources.”
- Centers for Disease Control and Prevention Public Response Hotline (1-888-246-2675)
- Agency for Toxic Substances and Disease Registry (1-888-422-8737)
- Regional Poison Control Center (1-800-222-1222)
Sources:
Agency for Toxic Substances and Disease Registry. 2004. ToxFAQs for Ammonia. Division of Toxicology, U.S. Department of Health and Human Services. Public Health Service: Atlanta, GA. Accessed May 6, 2004. http://www.atsdr.cdc.gov/toxfaqs/tf.asp?id=10&tid=2
Agency for Toxic Substances and Disease Registry. 2004. Medical Management Guidelines (MMGs) for Ammonia. Division of Toxicology, U.S. Department of Health and Human Services. Public Health Service: Atlanta, GA. Accessed May 6, 2004. http://www.atsdr.cdc.gov/mmg/mmg.asp?id=7&tid=2
Centers for Disease Control and Prevention. 2003. Public Health Emergency Preparedness and Response Sheets. U.S. Department of Health and Human Services. Public Health Service: Atlanta, GA. Accessed May 6, 2004. http://www.bt.cdc.gov/agent/ammonia/index.asp
This fact sheet is based on the most current information. It may be updated as new information becomes available.
Smelling salts
I was delving into some reference material recently, trying to track down details of early treatment of mild head injury, and I was struck by the repeated mention of smelling salts as a folk remedy for this problem. But just what are smelling salts? Do they work and can they cause injury?
Although smelling salts have recently undergone a resurgence of interest by athletes as a pre‐game stimulant or as a “pick me up” when performance is flagging, it appears that little is really known or understood about these agents. Over time they have tended to remain a traditional part of the trainer’s kit (along with the ubiquitous sponge and cold sprays) rather than in the medical bag.
In the setting of sporting head injury, there are still many individuals and organisations that recommend the use of smelling salts to try and revive the injured athlete. Most recent sports medicine textbooks, however, emphatically state that smelling salts are contraindicated as they cause a withdrawal reaction, with the potential to cause or exacerbate spine injury.
Take, for example, this early guideline for the management of unconscious patients from The treatment to restore natural breathing and circulation published in 1878 by Dr Peter Shepherd, Surgeon Major, Army Medical Department and an Associate of the Order of St John of Jerusalem. His approach was fairly dogmatic:
Rule 1 – “To Maintain a Free Entrance of Air into the Windpipe – Cleanse the mouth and nostrils; open the mouth; draw forward the patient’s tongue, and keep it forward: an elastic band over the tongue and chin will answer the purpose. Remove all tight clothing from about the neck and chest.”
Rule 2 – “To Adjust the Patient’s Position ‐ Place the patient on his back on a flat surface, inclined a little from the feet upwards; raise and support the head and shoulders on a small firm cushion or folded article of dress under the shoulder blades.”
So far, so good, but now the approach gets a little beyond the usual on‐field emergency management.
Rule 3 – “Should a warm bath be procurable, the body may be placed in it up to the neck. Raise the body for twenty seconds in a sitting position, dash cold water against the chest and face, and pass ammonia under the nose. The patient should not be kept in a warm bath for longer than five to six minutes.”
Rule 4 – “To Excite Inspiration – During the employment of the above method excite the nostrils with snuff or smelling salts, tickle the throat with a feather. Rub the chest and face briskly, and dash cold and hot water alternately on them.”
Rule 5 – “To Induce Circulation and Warmth ‐ Wrap the patient in dry blankets and commence rubbing the limbs upwards firmly and energetically. The friction must be continued under the blankets or over the dry clothing. Promote the warmth of the body by the application of hot flannels, bottles or bladders of hot water, heated bricks etc., to the armpits, the pit of the stomach, between the thighs and the soles of the feet. On the restoration of life, when the power of swallowing has returned, a teaspoon of warm water, small quantities of wine, warm brandy and water, or coffee should be given. The patient should be kept in bed and a disposition to sleep encouraged. During reaction, large mustard plasters to the chest and below the shoulders will greatly relieve the distressed breathing.”
So one can see the team doctor of the Victorian era armed with his smelling salts, feather, hot flannels, heated bricks, brandy, coffee and mustard poultices (presumably with a team Sherpas to carry them all) performing a valuable service to sports teams. Our current team physician training does seem to lack a certain cachet when compared with those of our medical ancestors.
What are smelling salts?
By definition, they are any of preparations of ammonium carbonate ((NH4)2CO3H2O) and perfume, sniffed as a restorative or stimulant. Traditionally, they were sniffed as a stimulant to relieve faintness or swooning. Smelling salts may also simply be dilute ammonia dissolved in a mixture of water and ethanol and most forms of “smelling salts” available on the internet are this latter type of mixture. These mixtures should be more correctly termed “aromatic spirits of ammonia.”
It may be of interest to some that there is a surprisingly long history of the use of such agents. The term Hammoniacus sal appears in the writings of Pliny, although it is not known whether the term is identical to the more modern sal ammoniac, which was known to the alchemists as early as the 13 th century. Chaucer also noted the existence of sal ammoniac alongside a large number of other materia medica. This spirit was mainly used by textile dyers in the Middle Ages in the form of fermented urine to alter the colour of vegetable dyes.
In the 17 th century an aqueous solution of ammonia (also called aquila coelestis) was obtained from the distillation of shavings of harts’ horns and hooves. When crystallised, this chemical turned out to be ammonium carbonate and was initially called salt (or spirit) of hartshorn and later became known as smelling salts when mixed with perfumes. It is also known as “baker’s ammonia” and was a forerunner to the more modern leavening agents such as baking soda and baking powder.
How do smelling salts work?
Smelling salts are used to arouse consciousness because the release of ammonia (NH3) gas that accompanies their use irritates the membranes of the nose and lungs, and thereby triggers an inhalation reflex. This reflex alters the pattern of breathing, resulting in improved respiratory flow rates and possibly alertness.
Are smelling salts likely to work for sport‐related mild head injury? It is unlikely that the induced inhalational reflex has a significant therapeutic effect over and above the natural history of the condition. Increasing the respiratory rate alone certainly has no beneficial pathophysiological effect on the nature or underlying cause of concussive injury. Whether the salts increase alertness or improve reaction times or have other positive cognitive benefits remains to be proven scientifically.
Do smelling salts cause injury?
While there are numerous case reports of the toxicity of ammoniacal agents when ingested in large doses or inhaled in high concentration for prolonged periods there are, in fact, no reports of adverse health problems related to the use of smelling salts in sport.
The product information for commercially available smelling salts clearly recommends that the capsule or solution be held 10–15 cm away from the patient’s nose. This, I suspect, is designed to limit any direct burning effect on the nasal or oral mucosa from high concentrations of the inhaled ammonia. This risk is not a new one and as Charles Dickens so eloquently put it in Hard Times (chapter 16) “…on his way home…he took the precaution of stepping into a chemist’s shop and buying a bottle of the very strongest smelling‐salts. ‘By George!’ said Mr. Bounderby, ‘if she takes it in the fainting way, I’ll have the skin off her nose, at all events!”.
With regard to sporting concussions, the real danger is that reaching for smelling salts in this situation is not a substitute for a careful and complete neurological assessment. More serious head injuries may often masquerade in the early stages as a minor head injury and inexperienced carers may falsely assume that an initial improvement, thought to be due to the beneficial effects of smelling salts, may well mask the development of more sinister complications.
It is important to note that it is an inhalation reflex, not a neck movement, that is induced by smelling salts, which simply results in increased rate and depth of breathing. It is possible that holding the salts too close to the nose (
Conclusion
In Victorian historical tradition, smelling salts were an effective method of helping ladies who had fallen prey to fainting fits. In modern sports medicine, however, when used correctly, smelling salts are unlikely to have significant benefit or cause significant adverse effects in sport‐related head injury. The real danger is that the injudicious use of these agents as a substitute for a medical assessment may delay optimal treatment and, as such, should not be recommended.
Articles from British Journal of Sports Medicine are provided here courtesy of BMJ Publishing Group
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