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Electronic cigarettes
From WikEM
Contents
Background
- Nicotine containing products that are currently not regulated by the FDA
- On 4/25/14, the FDA proposed legislation to allow them to regulate e-cigarettes like other tobacco products[1]
- Nicotine usually suspended in a propylene glycol or vegetable glycerin solution (labeled as %PG/%VG)[2][3]
- From Sept 2010 - Feb 2014, there were 16,248 toxic exposures to traditional cigarettes and 2,405 toxic exposures to e-cigarettes[4]
- Exposures to e-cigarettes increased from 1/month to 215/month over that time period
Product Types
- Some are fixed products with no refill capabilities (Ex. Blu e-cigarettes) while others can be refilled with replacement nicotine fluid
- Common strengths include 6mg/ml (low), 12mg/ml (medium-low), 18mg/ml (medium), 24mg/ml (high) and 36mg/ml (Ultra-high)
- Common refill sizes range from 5ml to 30ml
- Products come in a variety of flavors that can be enticing to children
- Bubble gum, root beer, extreme soda, Ecto-cooler, Banana cream pie, toasted marshmallow, etc.
Pathophysiology
- Fatal intoxications are rare and estimates suggest 60mg - 500mg as a lethal dose. Traditional cigarettes deliver approximately 2mg of nicotine [5]
Absorption
- Absorbed transdermally, orally and via inhalation
Biphasic presentation
- Initially excitation secondary to excitation of the presynaptic nAChR which facilitates release of neurotransmitters
- Second phase characterized by desensitization of the receptors and decreased neurotransmitter release
Clinical Features
| Postive | Negative |
| Anxiolysis | Gastrointestinal Distress |
| Congnitive Enhancement | Hypothermia |
| Cerebrovasodilation | Emesis |
| Neuroprotection | Hypertension |
| Analgesia | Seizures |
| Antipscyhotic | Respiratory Distress |
Eye Pain
- Nicotine is also an irritant and eye pain is a frequent complaint
Fasciculations
- Due to the neuromuscular nicotinic activation
Hypersalivation
At high doses nicotine will activate muscarinic receptors
Biphasic presentation
- Initially present with excitation, N/V/D, salivation, tachycardia, hypertension, diaphoresis
- Delayed presentation is hypotension, bradycardia, hypoventilation, fasiculations, seizures, coma, and death
Evaluation
- Exposure to nicotine containing liquid
- Toxidrome similar to nicotinism
Work-Up
- CBC
- Chem 7
- Utox
Differential Diagnosis
- Anticholinergic Toxicity
- Organophosphate Toxicity
- Sympathomimetic Toxicity
- Neuroleptic Malignant Syndrome (NMS)
- Serotonin Syndrome
- Sepsis
Management
Decontamination
- Providers should wear appropriate PPE during decontamination.
- Neoprene or nitrile gloves and gown (latex and vinyl are ineffective)
- Dispose of all clothes in biohazard container
- Wash patient with soap and water
Supportive Care
- IVF, O2, Monitor
- Aggressive airway management is of utmost importance.
- Intubation often needed due to significant respiratory secretions / bronchospasm.
- Use nondepolarizing agent (Rocuronium or Vecuronium).
Antidotes
- Atropine
- Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
- May require massive dosage (hundreds of milligrams)
- Dosing[6]
- Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
- Once secretions controlled → start IV gtt 0.02-0.08 mg/kg/hr
- Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled
- Once secretions controlled → start IV gtt 0.025 mg/kg/hr
- Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
- Pralidoxime
- AKA 2-PAM
- For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.
- This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible.
- Dosing[6]
- Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed or 50 mg/hr infusion.
- Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed or 10-20 mg/kg/hr infusion.
Disposition
- Admit for symptomatic poisonings
See Also
References
- ↑ Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act PDF
- ↑ PG e-liquid, VG e-liquid or PG/VG Mix e-liqud? http://www.bestecig.com/help.asp?id=57
- ↑ Carmines EL, Gaworski CL. Toxicological evaluation of glycerin as a cigarette ingredient. Food Chem Toxicol. 2005 Oct;43(10):1521-39
- ↑ CDC reports. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm
- ↑ Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Arch Toxicol. 2014; 88: 5–7
- ↑ 6.0 6.1 Agency for Toxic Substances and Disease Registry, Case Studies in Environmental Medicine, Cholinesterase Inhibitors: Including Pesticides and Chemical Warfare Nerve Agents. Centers for Disease Control (CDC). PDF Accessed 06/21/15
