TOXICOLOGY & ADDICTION MEDICINE
Blue Blood Emergencies: Recognition and Management of Nitrite and Nitrous Oxide Toxicity SAEM PULSE | MARCH-APRIL 2026
By Joeseph Champoux, PharmD, MBA, and Deepika Sivakumar, PharmD, MS
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Rising Use and Emerging Toxicity Nitrogen-containing compounds have been used in the United States for decades for medical, agricultural and industrial purposes. Nitrous oxide (N₂O) has long served as an anesthetic, while certain nitrites (sodium and alkyl) have been used in food preservation and medicine. Recently, however, illicit use of these substances has increased. According to the American Poison
Centers annual report, exposures to nitrates and nitrites are rising and have resulted in severe toxicity and death. In 2024, there were 1,076 reported cases involving nitrates or nitrites, with 16 cases resulting in major toxicity and 19 deaths. Although nitrous oxide and nitrites are chemically related, their mechanisms of toxicity differ and require distinct management strategies.
Nitrous Oxide: Mechanism and Acute Effects
Nitrous oxide has been used medicinally since the 18th century, when Humphry Davy first described its euphoric effects, earning it the nickname “laughing gas.” Today, it is misused recreationally under names such as “whippets” or “Galaxy Gas.” When inhaled, nitrous oxide rapidly displaces oxygen in the alveoli, potentially causing hypoxia. It quickly