Liquid Nicotine

Vape DangerTobacco smoke is a health hazard for children (and us children of all ages).  We know this.  So it seems like movement away for cigarettes is good for everyone; however, the thirst for nicotine is still quite strong and is often satiated by electronic cigarettes (“e-cig”).  The overall safety of these devices is still to be determined, but it is important for us to realize that the kids are great at uncovering danger in almost everything (see Laundry Detergent Pods).  Let us review the potential hazard of Liquid Nicotine. {much appreciation to Dr. Christine Murphy for her expert insights!}

 

Childhood Poisoning

  • In the US, > 300 children / Day require treatment for poisonings. [CDC]
  • Over 50% of all ED visits for poisoning were for children <4 years of age. [Nalliah, 2014]
  • The majority of poisonings are unintentional in young children.
  • The Home is a Dangerous Place!
    • Over 90% of all toxic exposures occur in homes.
    • Liquid Nicotine exposures occur primarily in a child’s own residence. [Forrester, 2015]
    • The liquid nicotine containers are not currently sold in child proof packaging.
    • The packaging is often colorful and are often flavored – enticing to children. [Normandin, 2015]
    • Frequency of nicotine toxic exposure has increased over past several years. [Kamboj, 2016]

 

Liquid Nicotine: E-Cigs

  • Electronic cigarettes have been promoted as a tool for smoking cessation.
    • Primary benefit would be in reducing tobacco smoke exposure, and potentially reducing long-term sequelae.
    • Evidence shows that teenagers who have never used cigarettes now start using electronic cigarettes though (so not just a smoking cessation tool). [Lowry, 2014]
    • Acute poisoning from tobacco products is due to the nicotine.
  • Electronic cigarettes
    • E-cigs are battery-powered implements that heat a liquid solution to make vapors that are then inhaled.
    • Microprocessors detect inhalation force and trigger the heating process.
    • The liquid may contain flavors, various chemicals (ex, propylene glycol, glycerol), and liquid nicotine.
  • Liquid Nicotine
    • Formulations of liquid nicotine products vary greatly. [Forrester, 2015]
    • Nicotine concentrations range from 18mg/mL to 100mg/mL.

 

Nicotine Toxicity

  • Nicotine is readily absorbed through the lungs, skin, GI tract, and mucous membranes.
  • Ingestion is the most common exposure route, but can also occur by dermal, ocular, and inhalation routes.
  • Toxic Dose is not exactly know, but estimated at 1.4mg/kg.
  • Toxic Symptoms

    • Mild
      • Nausea/vomiting
        • Vomiting is the most common significant symptom (24%) [Forrester, 2015]
      • Tremors
      • Tachycardia, tachypnea, elevated blood pressure
    • Severe
      • Salivation, diaphoresis
      • Dysrhythmia, fasciculations
      • Headache, dizziness, ataxia
      • Seizures, drowsiness, coma, respiratory failure
      • Fatalities have been reported [Eggleston, 2016; Normandin, 2015]

 

Nicotine Toxicity Treatment

  • Airway, Breathing, Circulation, Disability, and Exposure.
  • As with all possible toxic exposures, decontamination is important.
    • Remove any soiled clothing.
    • Flush eyes for ocular exposure.
    • Rinse other areas of dermal exposure.
  • Symptomatic management is the primary strategy.
    • Be aware that seizures may present before vomiting.
    • Patients with symptoms should be observed until asymptomatic with normal vital signs.
  • Treat seizures with benzodiazepines. If intractable seizures, give more benzos, rather than anti-epileptics. [Dr. Murphy communication – of course the toxicologist would advocate for “more benzos.”]
  • While activated charcoal can absorb nicotine, it is not recommended due to the fact that onset of symptoms is rapid and often complicated by vomiting and seizures (both of which do not go well with charcoal).

 

Moral of the Morsel

  • If there is potential danger, kids will find it.
  • Liquid nicotine comes in attractive and enticing packaging that is not child-proofed.
  • Liquid nicotine comes is very concentrated forms.
  • Seizures may occur in severe toxic exposures even before emesis.
  • Treat seizures with benzos… and more benzos.
  • Take time to educate families about possible hazards before them become a critical event!

 

References

Eggleston W1, Nacca N2, Stork CM1, Marraffa JM1. Pediatric death after unintentional exposure to liquid nicotine for an electronic cigarette. Clin Toxicol (Phila). 2016 Jul 7:1-2. PMID: 27383772. [PubMed] [Read by QxMD]
Forrester MB1. Pediatric Exposures to Electronic Cigarettes Reported to Texas Poison Centers. J Emerg Med. 2015 Aug;49(2):136-42. PMID: 25802158. [PubMed] [Read by QxMD]

Normandin PA1, Benotti SA2. Pediatric Emergency Update: Lethality of Liquid Nicotine in E-Cigarettes. J Emerg Nurs. 2015 Jul;41(4):357-9. PMID: 25913384. [PubMed] [Read by QxMD]
Garbutt JM1, Miller W2, Dodd S2, Bobenhouse N2, Sterkel R3, Strunk RC2. Parental Use of Electronic Cigarettes. Acad Pediatr. 2015 Nov-Dec;15(6):599-604. PMID: 26306662. [PubMed] [Read by QxMD]

Collaco JM1, Drummond MB2, McGrath-Morrow SA1. Electronic cigarette use and exposure in the pediatric population. JAMA Pediatr. 2015 Feb;169(2):177-82. PMID: 25546699. [PubMed] [Read by QxMD]

Gill N1, Sangha G1, Poonai N1, Lim R1. E-Cigarette Liquid Nicotine Ingestion in a Child: Case Report and Discussion. CJEM. 2015 Nov;17(6):699-703. PMID: 25892642. [PubMed] [Read by QxMD]

Nalliah RP1, Anderson IM, Lee MK, Rampa S, Allareddy V, Allareddy V. Children in the United States make close to 200,000 emergency department visits due to poisoning each year. Pediatr Emerg Care. 2014 Jul;30(7):453-7. PMID: 24977994. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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