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)
• 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

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

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
• Urine toxicology screen

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)
  • Succinylcholine is absolutely contraindicated
• Benzodiazepines for seizures

Antidotes

• Dosing with atropine and pralidoxime are time dependent and provides ability to reverse symptoms while awaiting agent metabolism
• For exposure to nerve agents, manufactured IM autoinjectors are available for rapid administration:
  • Mark 1
    • Contains 2 separate cartridges: atropine 2 mg + 2-PAM 600 mg
    • Being phased out with newer kits
  • DuoDote
    • Single autoinjector containing both medications
    • Same doses as Mark 1: atropine 2 mg + 2-PAM 600 mg

Antidotes

Atropine

• First-line antidote — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions
• Does NOT reverse nicotinic symptoms (weakness, fasciculations, paralysis)
• Starting dose: 1-2 mg IV (pediatric: 0.02-0.05 mg/kg, minimum 0.1 mg)
• Doubling protocol: If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved
• Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported
• Endpoints of adequate atropinization (goal of therapy):
  • Drying of bronchial secretions (most important endpoint)
  • Heart rate >80 bpm
  • Systolic BP >80 mmHg
• Do NOT target: Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity
• After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect
• Optimize oxygenation before giving atropine to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)

Pralidoxime

• AKA 2-PAM
• Oxime that reactivates phosphorylated AChE → primarily reverses nicotinic symptoms (weakness, fasciculations, respiratory muscle paralysis)
• Must give atropine BEFORE pralidoxime to prevent worsening of muscarinic symptoms
• Must be given before aging occurs (see aging table above)
• Adult dose: 1-2 g IV over 15-30 minutes, may repeat in 1 hour; or 30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion
• Pediatric dose: 20-50 mg/kg IV, then 5-10 mg/kg/hr infusion
• Continue until clinical improvement or patient is off ventilator
• Controversies:
  • Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine
  • However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present
  • Efficacy depends on timing (before aging), dose, and the specific OP compound involved
• Caution: Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest

Disposition

• Admit for symptomatic poisonings

See Also

Nicotine Poisoning