By Melissa Beckmann, MD
Emergency Medicine Resident
Introduction
E-cigarettes are a new trend that is gaining immense popularity. The refills for these cigarettes are potent liquid nicotine. Most range from 1.8-2.4% nicotine, however concentrations of up to 10% nicotine can be found on the Internet [1]. Some refill bottles contain 500 to 1000 mg of nicotine per ounce. Currently these are not FDA regulated. E-cigarette exposure calls accounted for an increasing percentage of poison center calls regarding cigarette exposure, increasing from 0.3% in September 2010 to 41.7% in February 2014 [2]
Emergency Medicine Resident
Introduction
E-cigarettes are a new trend that is gaining immense popularity. The refills for these cigarettes are potent liquid nicotine. Most range from 1.8-2.4% nicotine, however concentrations of up to 10% nicotine can be found on the Internet [1]. Some refill bottles contain 500 to 1000 mg of nicotine per ounce. Currently these are not FDA regulated. E-cigarette exposure calls accounted for an increasing percentage of poison center calls regarding cigarette exposure, increasing from 0.3% in September 2010 to 41.7% in February 2014 [2]
The figure above shows the number of calls to poison centers for cigarette or e-cigarette exposures, by month, in the United States during September 2010–February 2014. E-cigarette exposure calls per month increased from one in September 2010 to 215 in February 2014.
Use and experimentation among teenagers has also increased. In 2011-2012 e-cigarette experimentation and reported recent use among US middle and high schoolers more than doubled. It was estimated that in 2012, 1.78 million students experimented or reported recent use of e-cigarettes [3]. Multiple animal deaths, 1 human death (adult intentional overdose), multiple unintentional child exposures have been documented. The LD50 was thought to be 0.5-1 mg/kg but re-evaluation in 2013-showed 6.5-13 mg/kg. A vial of even 12 mg/ml of liquid nicotine would contain considerably more than enough to kill a child (4).
Nicotine is readily absorbed through the skin and has long been known to cause toxicity. Tobacco harvesters have been known to develop “Green Tobacco Sickness” from collecting wet tobacco leaves with their bare hands and subsequently absorbing the nicotine [5]. Symptoms include: nausea, vomiting, headache, dizziness, severe weakness, abdominal pain and SOB. Symptoms resolved in about 2 days.
Mechanism of Action
Nicotine is a nicotinic acetylcholine receptor agonist. Nicotinic receptors are found at the neuromuscular junction, autonomic ganglia, CNS and adrenal medulla. Binding of the nicotinic receptor causes the ion channel to open, allowing sodium, potassium and occasionally calcium to enter the cell.
Symptoms [4,6]
Symptoms include: nausea, vomiting, headache, dizziness, severe weakness, abdominal pain and SOB.
Symptoms resolved in about 2 days and are dose dependent. At low doses a stimulatory effect ensues. At high doses neuromuscular blockade develops.
Toxic side effects are also time dependent. In the first 15 min to one hour after overdose patients develop nausea, vomiting, excessive salivation, abdominal pain, sweating, hypertension, tachycardia ataxia, tremor, headache, dizziness, muscle fasciculations and seizure. Thirty minutes to four hours after exposure patients may develop hypotension, bradycardia, CNS depression, coma, muscle weakness, paralysis and respiratory difficulty/failure.
Treatment [4]
Treatment is mainly supportive. Activated charcoal may be helpful in reducing GI absorption but only if the patient presents within one hour of ingestion. Benzo’s can be used to treat seizure, IV fluids for hypotension, atropine for bradycardia and of course intubation if respiratory distress or failure develops. Hemodialysis is not effective at removing the toxin.
Prognosis
Typically patients make a full recover. If they can survive the first four hours then full recovery is likely. If sequelae do develop they are usually secondary to hypoxia due to prolonged seizure and/or respiratory failure.
References
Nicotine is readily absorbed through the skin and has long been known to cause toxicity. Tobacco harvesters have been known to develop “Green Tobacco Sickness” from collecting wet tobacco leaves with their bare hands and subsequently absorbing the nicotine [5]. Symptoms include: nausea, vomiting, headache, dizziness, severe weakness, abdominal pain and SOB. Symptoms resolved in about 2 days.
Mechanism of Action
Nicotine is a nicotinic acetylcholine receptor agonist. Nicotinic receptors are found at the neuromuscular junction, autonomic ganglia, CNS and adrenal medulla. Binding of the nicotinic receptor causes the ion channel to open, allowing sodium, potassium and occasionally calcium to enter the cell.
Symptoms [4,6]
Symptoms include: nausea, vomiting, headache, dizziness, severe weakness, abdominal pain and SOB.
Symptoms resolved in about 2 days and are dose dependent. At low doses a stimulatory effect ensues. At high doses neuromuscular blockade develops.
Toxic side effects are also time dependent. In the first 15 min to one hour after overdose patients develop nausea, vomiting, excessive salivation, abdominal pain, sweating, hypertension, tachycardia ataxia, tremor, headache, dizziness, muscle fasciculations and seizure. Thirty minutes to four hours after exposure patients may develop hypotension, bradycardia, CNS depression, coma, muscle weakness, paralysis and respiratory difficulty/failure.
Treatment [4]
Treatment is mainly supportive. Activated charcoal may be helpful in reducing GI absorption but only if the patient presents within one hour of ingestion. Benzo’s can be used to treat seizure, IV fluids for hypotension, atropine for bradycardia and of course intubation if respiratory distress or failure develops. Hemodialysis is not effective at removing the toxin.
Prognosis
Typically patients make a full recover. If they can survive the first four hours then full recovery is likely. If sequelae do develop they are usually secondary to hypoxia due to prolonged seizure and/or respiratory failure.
References
- Bassett RA, Osterhoudt K, Brabazon T. Nicotine Poisoning in an Infant. N Engl J Med. 2014.
- Chatham-stephens K, Law R, Taylor E, et al. Notes from the field: calls to poison centers for exposures to electronic cigarettes--United States, September 2010-February 2014. MMWR Morb Mortal Wkly Rep. 2014;63(13):292-3.
- Notes from the field: electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2013;62(35):729-30.
- Nelson L, Lewin N, Howland MA et al. Goldfranks Toxicologic Emergencies 10/E. McGraw-Hill Professional; 2014.
- Green tobacco sickness in tobacco harvesters--Kentucky, 1992. MMWR Morb Mortal Wkly Rep. 1993;42(13):237-40.
- Available at: http://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750028.html. Accessed April 10, 2014.
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