Electronic cigarettes

Revision as of 18:39, 11 June 2014 by Ostermayer (talk | contribs)

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

  • 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

See Also

Source

  1. ↑ Carmines EL, Gaworski CL. Toxicological evaluation of glycerin as a cigarette ingredient. Food Chem Toxicol. 2005 Oct;43(10):1521-39
  2. ↑ CDC reports. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm
  3. ↑ 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
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