liquidNicotine

Electronic Cigarettes and Liquid Nicotine Poisoning

By Jhonny E Ordonez, Larissa Velez**, and Kurt C Kleinschmidt**
*Toxicology Fellow, UTSW
**Professor of Emergency Medicine / Toxicology, UTSW

Case

A 3 year-old boy is found by his parents with an open container of liquid nicotine, which his dad uses to refill his electronic cigarette. The toddler had just drunk some and the rest of the solution is spilled over his clothes and skin. The child soon becomes agitated and has vomiting, pallor, and tremor. He then has a generalized tonic clonic seizure. He is brought to the ED by ambulance.  What would you do?

What are e-cigarettes?

Electronic cigarettes, also known as e-cigarettes (e-cigs) or electronic nicotine delivery systems (ENDS) are battery-powered devices that heat a liquid solution of nicotine, or e-liquid. An e-cigarette contains a cartridge that is either disposable or refillable. This cartridge contains the liquid nicotine that is heated and vaporized, and inhaling this vapor is called “vaping.” E-cigarettes were first developed in China in 2003 and rapidly became very popular throughout Asia and Europe. They have become popular in the USA since first being marketed in 2007. E-cigs have become popular as reportedly safer alternatives to smoking. They do not expose smokers to some of the dangerous product of pyrolysis. There is no smoke produced; only vapor, which is more acceptable to those around the smoker. The use of these devices is often allowed in places where smoking is prohibited. In the past, e-cigs were also marketed as smoking cessation aids. Currently, there is no evidence that e-cigarettes are effective methods to quit smoking.20

There have been recent concerns about other chemicals in the e-liquid, besides nicotine. The vapor contents include cytotoxic substances; acrolein, acetaldehyde, and formaldehyde.7,8 Although found in small concentrations, the potential chronic effects of inhaling these is unknown. Propylene glycol and glycerin are also in e-cigs as moisturizers. There are reports of these agents causing slight irritation when inhaled.3,9

Nicotine poisoning

Nicotine is an agonist at the nicotinic acetylcholine receptors. Acute nicotine poisoning has a biphasic pattern. The early clinical phase is characterized by excessive stimulation, resulting in nausea, vomiting, pallor, abdominal pain, salivation, bronchorrhea, tachypnea, hypertension, tachycardia, miosis, ataxia, tremor, fasciculations, and seizures. The delayed phase consists of central nervous system and respiratory depression, dyspnea, bradycardia, hypotension, shock, mydriasis, weakness, muscle paralysis, and coma.13 There are few reports of fatal cases after exposure to nicotine-containing products and plants by several routes.11,15 To this date, there are no reports of deaths from accidental liquid nicotine exposure.

The management of acute nicotine poisoning is mainly supportive.  Decontamination by washing the skin and removing clothes is appropriate for dermal exposures. Benzodiazepines are used for seizures. Intubation might be needed for those with muscle weakness or ventilatory failure. Atropine can be used for symptomatic bradycardia.

Why are they dangerous?

Exposure to the nicotine solutions may be dangerous because they may be highly concentrated, with concentrations ranging from 6 to 100 mg/ml.18 The lethal dose of nicotine is uncertain but the oral LD50 is 6.5–13 mg/kg in dogs.12 Based on this LD50, the ingestion of only a few milliliters of some of the preparations could be toxic. In children, doses as low as 0.1 mg/kg can cause toxicity. For comparison, one cigarette has about 20-30 mg of nicotine, and historically, ingestion of one cigarette has caused clinical toxicity in a child. The volumes available for sale may be as large as 1 liter, compounding on the potential for significant morbidity.

The product packaging also yields potential problems. E-cigarettes are not subject to regulation by the FDA; therefore, there is no requirement for childproof packaging. Colorful packaging and attractive flavorings both make these solutions target for children. There is no current requirement to do any labeling regarding the dangers of these liquid solutions. Many people are not aware of the potential risk of toxicity if the liquid nicotine is ingested or absorbed through the skin, especially small children who can be exposed to these products at home. Many of these containers are left accessible and unattended, where small children can easily obtain them.

Another serious concern is the intentional use and abuse of e-cigs by older children and teenagers.  The CDC reports that the percentage of U.S middle and high school students who use e-cigs more than doubled from 2011 to 2012.  The percentage of high school students who reported ever using an e-cigarette rose from 4.7% in 2011 to 10% in 2012. Recently, a bill that prohibits advertisement, promotion, or marketing of electronic cigarettes to children under the age of 18 was approved.23 Although the sales of cigarettes have stayed relatively flat in the past years, the sales of e-cigarettes are growing.22

Little is known about the impact of exposure on overall public health. Poison Center calls have experienced a surge in the past year, averaging 200 calls per day in early 2014.21 Most of the exposures reported to US Poison Centers are unintentional, and about ½ of them are in the 0-5 years age group.21

Although no deaths have been reported after accidental exposures to liquid nicotine, the potential for significant morbidity and mortality exists.

So what happened to our patient?

The patient’s clothes had a strong odor of vanilla (the flavoring on the liquid nicotine), so they were removed and the skin was washed. He was admitted to the pediatrics service, where he remained sleepy for the next 4 hours. He did not have any other significant clinical findings of nicotine poisoning. There was no recurrence of the seizure. The parents were educated on the dangers of highly concentrated liquid nicotine solutions. The patient was discharged home 12 hours after the exposure.

References / Further Reading

  1. Bertholon J.F., Becquemin M.H., Annesi-Maesano I., & Dautzenberg B. (2013). Electronic Cigarettes: A Short Review. Respiration, 86, 433-438. doi: 10.1159/000353253
  2. Cantrell L. E. (2013). Cigarette exposures – nothing to get choked up about. Clinical Toxicology, 51, 684-685.
  3. Carmines EL, Gaworski CL. (2005). Toxicological evaluation of glycerin as a cigarette ingredient. Food Chem Toxicol 43(10):1521-39.
  4. Deyton L.R. (2013). Regulation of E-Cigarettes and Other Tobacco Products. FDA U.S. Food and Drug Administration.
  5. Etter J. F., & Bullen C. (2011). Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction, 106, 2017-2028. doi:10.1111/j.1360-0443.2011.03505.x
  6. Etter J.F., & Bullen C. (2013). A longitudinal study of electronic cigarette users. Addictive Behaviors, 39, 491-494.
  7. Goniewicz M.L., Knysak J., Gawron M., Knysak J., & Kosmider L. (2013). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control, doi: 10.1136/tobaccocontrol-2012-050859:1–7
  8. Goniewicz M.L., Kuma T., Gawron M., Knysak J. & Kosmider L. (2013). Nicotine Levels in Electronic Cigarettes. Nicotine & Tobacco Research, 15, 158-166. doi:10.1093/ntr/nts103
  9. Gaworski C, Oldhama MJ, Cogginsb C. (2010). Toxicological considerations on the use of propylene glycol as a humectant in cigarettes. Toxicology 269, 54–66
  10. Jun Ho Cho J.H., Shin E., & Sang-Sik Moon (2011). Electronic-Cigarette Smoking Experience Among Adolescents. Journal of Adolescent Health, 49, 542–546. doi:10.1016/j.jadohealth.2011.08.001
  11. Lavoie F.W., & Harris .TM. (1991). Fatal nicotine ingestion. The Journal of Emergency Medicine, 9, 133-136.
  12. Mayer B. (2014). How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology, 88, 5–7. doi: 10.1007/s00204-013-1127-0
  13. Metz C.N., Gregersen P.K., & Malhotra A.K. (2004). Metabolism and biochemical effects of nicotine for primary care providers. The Medical Clinics of North America, 88, 1399–1413. doi:10.1016/j.mcna.2004.06.004
  14. Pepper J.K., & Brewer N.T. (2013). Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review. Tobacco Control, 1-10. doi:10.1136/051122
  15. Solarino B., Rosenbaum F., Rießelmann B., Buschmann C.T. & Tsokos M. (2010). Death due to ingestion of nicotine-containing solution: case report and review of the literature. Forensic Science International, 195, 19-22. doi:10.1016/j.forsciint.2009.11.00
  16. Sutfin E.L., McCoyb T.P., Morrell H.E., Hoeppner B.B. & Wolfson M. (2013). Electronic cigarette use by college students. Drug and Alcohol Dependence, 131, 214–221.
  17. Thornton S., Oller L., & Sawyer T. (2013). Fatal intravenous injection of electronic cigarette “eLiquid” solution. Clinical Toxicology, 51, 683.
  18. Retrieved from www.myfreedomsmokes.com
  19. Valento M. (2013). Nicotine poisoning following ingestion of e-Liquid. Clinical Toxicology, 51,683-684.
  20. Bullen C, Howe C, Laugesen M, et al (2013). Electronic cigarettes for smoking cessation: a randomized controlled trial. Lancet, 382, 1629–37
  21. Chatham-Stephens K, MD1, Law R, Taylor E, et al (2014). Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014 Weekly. 63(13); 292-293. (Accessed on 05/06/2014)
  22. Herzog B,  Gerberi J, (2013). Equity Research. E-Cigs Revolutionizing The Tobacco Industry. Wells Fargo securities.(Accessed on 05/08/2014)
  23. Library of Congress. S.2047 – 113th Congress (2013-2014): Protecting Children from Electronic Cigarette Advertising Act of 2014. (Accessed on 05/13/2014)
Edited by Alex Koyfman

2 thoughts on “Electronic Cigarettes and Liquid Nicotine Poisoning”

  1. I am a NY state paramedic. My agency was called a couple of days ago for a 18 month old that overdosed on a 100mg/ml solution that had been left unattended & within reach of the child. The child was apneic & unresponsive upon our arrival & CPR had been initiated. The child was in asystole. We were unable to achieve ROSC. It is now a fact, It isn’t just lethal hypothetically. It is, as far as I’m concerned, lethal. I have already educated my coworkers as to the pathophysiology of Nicotine & S/S of overdose but there definitely needs to be more educational information made available to us on the front line since I believe we will be seeing more & more of these OD’s in the future. Thank you for your time.

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