Electronic cigarettes: Difference between revisions
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==Treatment== | ==Treatment== | ||
{{Anticholinergic Toxicity}} | {{Anticholinergic Toxicity Treatement}} | ||
==Disposition== | ==Disposition== | ||
Revision as of 19:04, 11 June 2014
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
- Nicotine usually suspended in a propylene glycol or vegetable glycerin solution (labeled as %PG/%VG)[1]
- Increasing toxic exposure to e-cigarettes
- From Sept 2010 - Feb 2014, there were 16,248 toxic exposures to traditional cigarettes and 2,405 toxic exposures to e-cigarettes[2]
- 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 as a lethal dose. Traditional cigarettes deliver approximately 2mg of icotine [3]
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
- Highly variable presentation
- Tobacco is a GI irritant and often causes spontaneous vomiting
- Biphasic presentation
- Initially present with excitation, N/V/D, salivation, tachycardia, hypertension, diaphoresis
- Delayed presentation is hypotension, bradycardia, hypoventilation, fasiculations, seizures, coma, death
Diagnosis
- Exposure to nicotine containing liquid
- Toxidrome similar to nicotinism
Work-Up
- CBC
- Chem 7
- Utox
DDx
- Anticholinergic toxicity
Treatment
Treatment
- Consider GI decon with Activated Charcoal if patient presents <2 hours after ingestion and remains cooperative
Sedation
- Decreases the risk of hyperthermia, rhabdo, traumatic injuries
- Benzos are agents of choice especially increase seizure threshold[4]
- Repeat boluses every 5-15 minutes as needed to halt seizures and provide adequate sedation
- Goal: QRS duration < 110 msec
Cholinesterase inhibition
- Indicated for severe agitation or delirium (esp if unresponsive to benzos)
- Contraindicated in QRS>100 or Na blockade signs (R' in aVR) and in narrow angle glaucoma
- Relatively contraindicated in asthma or ileus
- Physostigmine - strongly consider poison control consult before giving
- Crosses blood brain barrier, can be used to help make dx
- Dosing: 0.5mg-1mg IV over 5min (repeat dosing up to 2mg in first hour)[5]
- Onset of action: 5-10min
- If partial response, repeat x3
- If 3 or more administrations are needed over a 6-hour period, start IV infusion (bolus 1-2 mg followed by 1 mg/hour)
- Stop infusion every 12 hours to determine resolution of the toxidrome
- Side effects: bradycardia, dysrhythmias, cholinergic excess[6]
- Always have atropine at the bedside for bradycardia or cholinergic excess</ref>[7]
- Contraindicated in TCA toxicity (associated with cardiac arrest) and in the presence of bradycardia or AV block
Other therapies
- Sodium bicarbonate for conduction abnormalities (QRS prolongation)
- 2 mEq/kg bolus (typically 2-3 amps of bicarb)
- Begin continuous NaCO3 infusion at 250mL/hr if bolus effective
- Solution preparation = 1L D5W mixed with 3 ampules NaHCO3
Disposition
- Admit for symptomatic poisonings
See Also
Source
- http://www.bestecig.com/help.asp?id=57
- https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-09491.pdf
- ↑ 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
- ↑ Burns MJ, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000:35(4):374-381.
- ↑ Rosenbaum C and Bird SB. Timing and frequency for physostigmine redosing for antimuscarininc toxicity. J Med Toxicol. 2010;6:386-92.
- ↑ Pentel P and Peterson CD. Aystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med. 1980 Nov;9(11):588-90.
- ↑ Nguyen TT, et al. Adverse events from physostigmine: an observational study. Am J Emerg Med. 2018;36:141-2.