Ammonia

For the treatment of fainting (syncope) in adults, the standard procedure involves the inhalation of Ammonia vapors.

• Inhalant Ampules: A single ampule (typically containing 0.3 mL to 0.4 mL of Aromatic Ammonia Spirit) is crushed and held approximately 4 to 6 inches (10 to 15 cm) away from the nostrils. The patient should be instructed to take a brief, deep breath. If consciousness is not restored within seconds, the ampule may be wafted again, but repeated use should be avoided if the patient remains unresponsive.
• Liquid Solution: If using the liquid spirit, 1 to 2 drops may be placed on a cotton swab or gauze and held near the nose.

Ammonia must be used with extreme caution in the pediatric population.

• Children (Age 12 and older): The dosage and administration are similar to adults, but the inhalant should be held further away (6 to 10 inches) to prevent excessive irritation of the delicate nasal passages.
• Children (Under Age 12): Safety and efficacy have not been firmly established for young children. Many healthcare providers recommend against the use of ammonia inhalants in infants and toddlers due to the risk of inducing laryngeal spasms or severe respiratory distress. Always consult a pediatrician before use in this age group.

Renal Impairment

Because the medicinal use of Ammonia involves a single, minute dose that triggers a reflex rather than requiring high systemic concentrations, dosage adjustments for renal impairment are generally not necessary for acute use. However, patients with end-stage renal disease (ESRD) already have elevated blood urea nitrogen (BUN) and potentially higher systemic ammonia levels; therefore, repeated use should be avoided.

Hepatic Impairment

Patients with severe hepatic impairment (e.g., Cirrhosis, Child-Pugh Class C) may have a reduced ability to process ammonia via the urea cycle. While a single inhalation is unlikely to cause systemic toxicity, healthcare providers should exercise caution in patients with hepatic encephalopathy, where even small increases in ammonia could theoretically be detrimental.

Elderly Patients

Elderly patients may have more fragile nasal mucosa and a higher prevalence of underlying cardiovascular disease. The inhalant should be held at the maximum recommended distance (6-8 inches) to avoid an overly aggressive sympathetic surge that could stress the heart.

Ammonia is for inhalation use only. It must never be swallowed, injected, or applied directly to the skin or eyes.

1. 1Positioning: Ensure the patient is lying flat on their back (supine) or sitting with their head between their knees before administration. This helps blood flow to the brain.
2. 2Preparation: If using an ampule, wrap it in a tissue or use the provided cloth sleeve before crushing it between your thumb and forefinger.
3. 3Wafting Technique: Do not hold the source of the ammonia directly against the nostrils. Instead, 'waft' the vapor toward the nose from a distance of several inches. This allows the patient to inhale a diluted concentration, reducing the risk of mucosal burns.
4. 4Storage: Store ammonia products at room temperature (59°F to 86°F or 15°C to 30°C). Keep them away from direct sunlight and heat, as ammonia gas can expand and cause containers to leak or burst.

Ammonia is used on an 'as-needed' basis for acute symptoms. There is no schedule for this medication, and therefore, missed doses are not applicable. Do not use this medication regularly or as a preventive measure without a doctor's order.

An overdose of inhaled ammonia occurs when the vapors are inhaled too deeply, too frequently, or held too close to the nose.

• Signs of Overdose: Severe burning sensation in the nose and throat, coughing, wheezing, shortness of breath (dyspnea), and watery eyes. In extreme cases, it can cause pulmonary edema (fluid in the lungs) or laryngeal spasm.
• Emergency Measures: Immediately move the person to an area with fresh air. If the patient is not breathing or is having difficulty breathing, call 911 or emergency services immediately. If the liquid has touched the skin or eyes, flush with large amounts of water for at least 15 minutes.

> Important: Follow your healthcare provider's dosing instructions. Do not adjust your dose or use ammonia for purposes other than those prescribed by a medical professional.

Because Ammonia is a potent chemical irritant, certain side effects are expected as part of its mechanism of action. These are usually transient and resolve shortly after the vapor is removed.

• Nasal Irritation: A sharp, stinging, or burning sensation in the nostrils immediately upon inhalation. This typically lasts for 30 to 60 seconds.
• Watery Eyes (Lacrimation): The vapors can irritate the tear ducts, causing the eyes to water briefly.
• Coughing: A sudden reflex cough is common as the respiratory system reacts to the pungent gas.
• Brief Headache: The sudden change in blood pressure and vasodilation can sometimes trigger a short-lived 'flash' headache.

• Sneezing: Repeated sneezing fits may occur as the nasal mucosa attempts to clear the irritant.
• Nausea: The strong, unpleasant odor can cause temporary feelings of queasiness or an upset stomach in sensitive individuals.
• Lightheadedness: While intended to treat fainting, the 'shock' of the inhalation can occasionally cause a brief period of secondary dizziness.
• Skin Redness: If the vapor is held too close to the face, the skin around the nose may become temporarily flushed or red.

• Bronchospasm: A sudden constriction of the muscles in the walls of the bronchioles, making it very difficult to breathe. This is more common in patients with pre-existing asthma.
• Mucosal Burns: If the liquid spirit comes into direct contact with the lining of the nose, it can cause chemical burns and tissue sloughing.
• Fainting Recurrence: In some cases, the intense irritation can trigger a paradoxical vasovagal response, leading the patient to faint again.

> Warning: Stop using Ammonia and call your doctor or emergency services immediately if you experience any of the following:

• Difficulty Breathing or Wheezing: This may indicate a severe respiratory reaction or the onset of pulmonary edema.
• Chest Pain or Rapid Heartbeat: The sympathetic surge caused by ammonia can put stress on the heart, potentially triggering arrhythmias in susceptible individuals.
• Swelling of the Throat or Tongue: This could be a sign of a rare allergic reaction or severe tissue irritation that could block the airway.
• Seizures: While extremely rare, the intense sensory input could theoretically lower the seizure threshold in predisposed patients.
• Vision Changes: If vapors or liquid enter the eyes, it can cause severe corneal irritation or burns that require urgent ophthalmological evaluation.

Ammonia is not intended for long-term or chronic use. Prolonged or frequent exposure to ammonia vapors can lead to:

• Chronic Rhinitis: Persistent inflammation of the nasal lining, leading to a constant runny or stuffy nose.
• Anosmia: A partial or complete loss of the sense of smell due to repeated damage to the olfactory receptors.
• Chronic Bronchitis: Repeated irritation of the lower airways can lead to permanent inflammatory changes.
• Dependency: While not chemically addictive, some individuals may become psychologically dependent on the 'jolt' provided by ammonia, masking underlying medical or psychological issues.

No FDA black box warnings are currently issued for Aromatic Ammonia Spirit. However, it is classified as a hazardous substance in high concentrations, and medical formulations must be used strictly according to the label instructions to avoid severe respiratory injury.

Report any unusual symptoms or persistent side effects to your healthcare provider. You may also report side effects to the FDA at 1-800-FDA-1088.

Ammonia is a powerful chemical and must be handled with care. It is intended only for the temporary relief of fainting and should never be used as a general 'pick-me-up' or to treat chronic fatigue. The most critical safety point is that Ammonia should only be used when the cause of fainting is known to be simple syncope. If a person has fainted due to a head injury, heart attack, or stroke, using ammonia could be dangerous or delay life-saving treatment.

There are currently no FDA black box warnings for Ammonia when used in medicinal inhalant forms. However, the absence of a black box warning does not imply that the drug is without risk. Its use is primarily governed by the OTC Monograph for reflex stimulants.

• Respiratory Conditions: Patients with asthma, emphysema, or chronic obstructive pulmonary disease (COPD) are at a significantly higher risk for bronchospasm. The irritation from ammonia can trigger a severe asthma attack that may not respond to standard rescue inhalers.
• Head and Neck Injuries: Never use ammonia on a person who may have a spinal or head injury. The reflex 'jerk' of the head away from the pungent odor can exacerbate a neck fracture or spinal cord injury.
• Skin and Eye Sensitivity: Ammonia is a caustic substance. Direct contact with the eyes can cause permanent damage, including corneal scarring. Direct skin contact can cause chemical burns, especially on the face or in the nostrils.
• Allergic Reactions: While rare, some individuals may be hypersensitive to the aromatic oils (lemon, lavender, nutmeg) found in Aromatic Ammonia Spirit. Signs of anaphylaxis (hives, swelling, difficulty breathing) require immediate emergency intervention.

Because Ammonia is used for acute, one-time events, long-term laboratory monitoring is generally not required. However, the following should be monitored during and after use:

• Vital Signs: Monitor heart rate and blood pressure immediately after the patient regains consciousness.
• Respiratory Status: Observe the patient for at least 30 minutes to ensure no delayed bronchospasm or respiratory distress occurs.
• Neurological Status: If the patient does not regain full consciousness or appears confused after the use of ammonia, immediate neurological evaluation is required to rule out stroke or seizure.

After an episode of fainting and the subsequent use of Ammonia, patients should not drive or operate heavy machinery until they have been cleared by a healthcare provider. The underlying cause of the fainting (e.g., cardiac arrhythmia) may recur, posing a significant safety risk.

Alcohol is a CNS depressant and a vasodilator, which can worsen the symptoms of syncope. Using Ammonia while intoxicated may result in a diminished reflex response or increased nausea and vomiting. It is generally advised to avoid alcohol if you are prone to fainting episodes.

There are no tapering requirements for Ammonia, as it is not used chronically. However, if you find yourself needing to use ammonia frequently, you must stop and consult a doctor to investigate the cause of your frequent fainting, as this may indicate a serious underlying heart or neurological condition.

> Important: Discuss all your medical conditions, especially respiratory or heart problems, with your healthcare provider before using Ammonia.

While Ammonia is an inhalant with minimal systemic absorption, certain combinations are strictly avoided due to the risk of severe physiological reactions:

• Other Strong Volatile Irritants: Using Ammonia in conjunction with other inhalant stimulants (like certain industrial solvents or high-concentration smelling salts) can cause cumulative damage to the respiratory mucosa and lead to severe laryngospasm.
• General Anesthetics (Volatile): If a patient is under or recovering from volatile general anesthesia (like halothane or isoflurane), the use of ammonia can cause unpredictable cardiovascular fluctuations and should be avoided unless directed by an anesthesiologist.

• Antihypertensive Medications: Ammonia triggers a brief rise in blood pressure. In patients taking potent blood pressure medications (e.g., nitroprusside or high-dose beta-blockers), this sudden surge can cause a 'clash' in cardiovascular signals, potentially leading to rebound hypotension or arrhythmias.
• Bronchodilators: Patients using daily bronchodilators (like salmeterol or tiotropium) for asthma or COPD may have an altered sensitivity to the irritant effects of ammonia. While it may seem counterintuitive, the ammonia may trigger a spasm that overrides the effect of the bronchodilator.

• CNS Stimulants: Medications used for ADHD (like methylphenidate or amphetamines) already increase the heart rate and sympathetic tone. Adding the sympathetic surge of ammonia can lead to excessive tachycardia (fast heart rate) or palpitations.
• CNS Depressants: Benzodiazepines or opioids may dampen the brain's reflex response to ammonia, making the drug less effective at restoring consciousness.

There are no known direct food interactions with inhaled Ammonia. However, patients who experience frequent fainting are often advised to monitor their salt and water intake. Dehydration can increase the risk of syncope, potentially leading to more frequent needs for ammonia.

• Ephedra/Ma Huang: This herbal stimulant can increase heart rate and blood pressure. Combining it with the effects of ammonia can cause dangerous spikes in cardiovascular stress.
• Vasoactive Supplements: Supplements like L-arginine or Nitric Oxide boosters, which cause vasodilation, may counteract the vasoconstrictive effect of ammonia, potentially reducing its efficacy in treating fainting.

• Blood Ammonia Levels: Inhaling medicinal ammonia is unlikely to significantly raise systemic blood ammonia levels in a healthy individual. However, if blood is drawn immediately after extensive or repeated use, a slight, transient elevation might be noted.
• Urine pH: Very high doses of systemic ammonia (usually from ammonium chloride salts, not inhalants) can acidify the urine, potentially affecting the excretion rates of other drugs.

For each interaction, the primary concern is the pharmacodynamic interaction, where the effects of the two substances on the heart, lungs, or brain either cancel each other out or combine to create an excessive, dangerous response.

> Important: Tell your doctor about ALL medications, supplements, and herbal products you are taking, especially if you have a history of respiratory or cardiovascular disease.

Ammonia must NEVER be used in the following circumstances:

• Known Hypersensitivity: If a patient has a documented allergy to ammonia or any of the aromatic oils in the spirit (lemon, lavender, nutmeg), use is strictly prohibited due to the risk of anaphylaxis.
• Asthma and Reactive Airway Disease: The risk of inducing a life-threatening bronchospasm is too high. Even a small amount of vapor can cause the airways to shut down in an asthmatic patient.
• Infants and Neonates: The respiratory system of an infant is highly sensitive. Ammonia can cause a 'Kratschmer reflex' (apnea and bradycardia) in very young children, which can be fatal.
• Direct Application to Eyes or Skin: Ammonia is caustic. It must never be applied to the skin or eyes, as it causes immediate chemical burns and tissue necrosis.
• Head or Neck Trauma: As previously noted, the involuntary reflex to pull away from the vapor can cause catastrophic injury to a damaged spinal cord or worsen a traumatic brain injury.

Conditions requiring careful risk-benefit analysis by a healthcare provider include:

• Cardiac Arrhythmias: The sudden sympathetic surge can trigger or worsen irregular heartbeats, such as atrial fibrillation or ventricular tachycardia.
• Pregnancy: While not strictly contraindicated, the stress of the fainting episode and the subsequent 'shock' of the ammonia should be managed carefully to avoid fetal distress.
• Severe Hepatic Disease: In patients with pre-existing hyperammonemia (high blood ammonia), even the small amount absorbed via inhalation must be weighed against the clinical need.

Patients who are sensitive to other nitrogenous compounds or strong chemical irritants may be more likely to have an exaggerated or adverse reaction to Ammonia. Additionally, those with 'Multiple Chemical Sensitivity' (MCS) may experience prolonged symptoms after exposure to the pungent odor of Aromatic Ammonia Spirit.

> Important: Your healthcare provider will evaluate your complete medical history, including any history of respiratory distress or heart disease, before prescribing or using Ammonia.

Ammonia is generally classified as FDA Pregnancy Category C. This means that animal reproduction studies have not been conducted, and there is no adequate and well-controlled data regarding its use in pregnant women.

• Trimester-Specific Risks: During the first trimester, the primary concern is the maternal stress response. In the third trimester, a sudden surge in maternal blood pressure could theoretically affect placental blood flow, though a single inhalation is unlikely to cause lasting harm.
• Clinical Recommendation: Ammonia should be used during pregnancy only if clearly needed and under medical supervision. The focus should be on placing the pregnant woman in a left-lateral recumbent position to restore blood flow naturally before resorting to chemical stimulants.

It is not known whether the components of Aromatic Ammonia Spirit are excreted in human milk. However, because the systemic absorption of inhaled ammonia is extremely low and the half-life of metabolized ammonia (urea) is short, it is considered unlikely to pose a risk to a nursing infant. As a precaution, avoid using the inhalant in close proximity to the infant to prevent the baby from inhaling the vapors.

• Approved Age Ranges: There is no formal FDA 'approved age,' but clinical practice generally limits use to children over the age of 12.
• Growth Effects: There are no known effects on growth with acute, as-needed use.
• Special Considerations: Children have smaller airways and more reactive mucosal linings. If ammonia is used, it must be held much further away from the face than in adults. Use in infants is strictly contraindicated due to the risk of reflex apnea (stopping breathing).

• Fall Risk: The primary concern in the elderly is the cause of the fainting. If an elderly person faints, it is often due to a cardiac issue or a medication side effect. Using ammonia may restore consciousness but does not address the risk of a secondary fall.
• Cardiovascular Sensitivity: Older adults are more sensitive to the catecholamine (adrenaline) surge triggered by the ammonia reflex, which can increase the risk of transient hypertension or palpitations.
• Renal Function: While acute use is safe, the elderly have naturally lower GFR (glomerular filtration rate), meaning any systemically absorbed ammonia will be cleared more slowly.

In patients with chronic kidney disease (CKD), the body's ability to excrete urea (the metabolite of ammonia) is diminished. While a single use for syncope is generally safe, repeated use in a patient with a GFR below 30 mL/min should be avoided to prevent any contribution to uremic symptoms.

In patients with liver failure or cirrhosis, the urea cycle is impaired. These patients are already at risk for hepatic encephalopathy due to elevated endogenous ammonia. While the amount of ammonia in a medicinal inhalant is small, it should be used with extreme caution in this population, as their 'ammonia buffer' is already compromised.

> Important: Special populations require individualized medical assessment. Always inform your doctor if you are pregnant, breastfeeding, or have chronic kidney or liver issues.

Ammonia acts as a reflex respiratory stimulant. Its primary molecular target is the sensory nerve endings of the trigeminal nerve (Cranial Nerve V) located in the nasal mucosa. Upon inhalation, the alkaline ammonia gas reacts with the moisture on the mucosal surface to form ammonium hydroxide, which briefly irritates the nerve endings.

This irritation sends an immediate afferent signal to the medulla oblongata in the brainstem. Specifically, it stimulates the inspiratory center and the vasomotor center. The result is a sudden, deep breath (reversing apnea or shallow breathing) and a transient increase in sympathetic outflow, which causes peripheral vasoconstriction and an increase in heart rate and blood pressure.

• Onset of Effect: Nearly instantaneous (within 1 to 5 seconds of inhalation).
• Duration of Effect: Very short (typically 1 to 2 minutes). The 'jolt' of alertness is temporary and serves only to bridge the patient back to consciousness.
• Dose-Response: There is a narrow therapeutic window. Too little vapor fails to trigger the reflex; too much vapor can cause laryngeal spasm or mucosal damage.
• Tolerance: While physical tolerance to the reflex does not develop with acute use, repeated frequent use can lead to mucosal desensitization.

| Parameter | Value |

|---|---|

| Bioavailability | High (local mucosal), Low (systemic) |

| Protein Binding | Negligible |

| Half-life | Minutes (as NH3), Hours (as Urea) |

| Tmax | Immediate (seconds) |

| Metabolism | Hepatic (Urea Cycle) |

| Excretion | Renal (>95% as Urea) |

• Molecular Formula: NH3
• Molecular Weight: 17.031 g/mol
• Solubility: Highly soluble in water, alcohol, and ether.
• Structure: A single nitrogen atom bonded to three hydrogen atoms in a trigeminal pyramidal geometry. In medicinal spirits, it exists in equilibrium with ammonium hydroxide (NH4OH).

Ammonia is classified as a Respiratory Stimulant (Inhalant). It is distinct from systemic stimulants like caffeine or amphetamines because it does not cross the blood-brain barrier to act on the central nervous system directly; rather, it works through a peripheral sensory reflex arc.