Electronic cigarettes

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)
• 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
    • Exposures to e-cigarettes increased from 1/month to 215/month over that time period
• Multiple variations on products exist
  • Some are fixed products with no refill capabilities (Ex. Blu e-cigarettes)
  • 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

• ADME
  • 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

• Decontamination
  • Activated charcoal
    • GI dialysis
  • Wear proper PPE
• Symptoms guide treatment
  • Atropine - Bradycardia
  • Fluids - Hypotension
  • Benzos - Seizures
  • Intubation/PPV - Respiratory failure

Disposition

• Admit for symptomatic poisonings

Source

• http://www.bestecig.com/help.asp?id=57
• https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-09491.pdf