10-19-2020: Which Age Groups are Injured by Liquid Nicotine?

Background: Electronic cigarettes or ‘e-cigarettes’ are the most used tobacco product among youth.3 The total number of middle and high school students reporting use of e-cigarettes surpassed 5 million in 2019.4 In 2020, 3.6 million U.S. middle and high school students used e-cigarettes in the past 30 days, including 4.7% of middle school students and 19.6% of high school students.3 Despite regulatory parameters for e-liquids, such as maximum nicotine concentration of 20 mg/ml having been already proposed worldwide, e-liquid solutions with nicotine concentrations of up to 60 mg/ml may be increasingly more easily purchased online, facilitating the occurrence of fatal cases following both accidental and intentional e-liquid intake – gradually becoming a relevant health problem worldwide.9

ecigs 2020 aapcc

Image courtesy of AAPCC, October 2020 1

In a recently published article in Clinical Toxicology, Wang et al found nearly 2/3 of nicotine liquid ingestions occur among children < 5 years.11  A systematic review of all reports of severe toxicity from liquid nicotine reported a bimodal distribution of patients’ age with nicotine intoxication – those >10 years are more likely to ingest nicotine intentionally, often as a suicide gesture.6 Not only is their advertising reaching a broader and younger audience, instructions have been made available online for those who wish to abuse/ingest nicotine for suicidal purposes.9

Lethal dose (median): 1-13mg/kg – As little as 1 tablespoon of “commercially available liquid nicotine is capable of killing four small children”. Even smaller levels of exposure to e-liquid, whether ingested or absorbed through the skin, can lead nausea, vomiting, cardiac arrest, seizures, or coma.5

Concentration: 6-36mg/ml (concentrations over 100-200mg/ml intended for dilution before use)7

Additives: Propylene glycol, vegetable glycerin, oil of wintergreen (among other flavors)

Presentation: Asymptomatic children who have a known ingestion of less than 1-2mg of liquid nicotine can be observed in the home2 – thanks to expert Poison Center guidance! Nicotine exposure can result in muscarinic symptoms (e.g. vomiting, diarrhea, bronchorrhea, salivation, wheezing) at low doses and nicotinic symptoms (e.g. muscle fasciculations, paralysis, somnolence, coma, seizures) at higher doses.  Biphasic pattern of hypertension, tachycardia, and vomiting followed by autonomic ganglion blockade causing hypotension, bradycardia, and coma.8

Approach:

Decontamination – Remove all clothing, flush eyes for ocular exposure, rinse skin for dermal exposure Gastric decontamination – Although activated charcoal adsorbs nicotine it is not recommended due to nicotine’s rapid onset of systemic toxicity often confounded by vomiting and seizures.  If your patient has a protected airway and has a known massive ingestion, activated charcoal may be considered. Increased elimination – Whole bowel irrigation, hemodialysis, and urine alkalization are not recommended

Therapy – Seizures should be treated with benzodiazepines.  Ondansetron for nausea/vomiting.  Atropine can be used for reversal of cholinergic symptoms in severe toxicity.2

Resources

1. American Association of Poison Control Centers: E-cigarettes and Liquid Nicotine. aapcc.com.  Accessed 10/9/2020.

2. Burns M, Bates B, & Wiley J. Toxic plant ingestions and nicotine poisoning in children: management. UptoDate. Last updated September 2020. Accessed 10/8/2020.

3. CDC: About Electronic Cigarettes. cdc.gov. Last updated September 2020. Accessed 10/8/2020.

4. FDA: Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS). fda.gov. Last updated September 2020. Accessed 10/8/2020.

5. Frey L & Tilburg W. Child-Resistant Packaging for E-Liquid: A Review of US State LegislationAm J Public Health. 2016;106(2):266-268.

6. Maessen, G et al. Nicotine intoxication by e-cigarette liquids: a study of case reports and pathophysiology. Clinical Toxicology. 2020; 58(1): 1-8.

7. Kamboj A, Spiller HA, Casavant MJ, Chounthirath T, Smith GA. Pediatric Exposure to E-Cigarettes, Nicotine, and Tobacco Products in the United States. Pediatrics. 2016. 137(6): e20160041.

8. Kim, Ji Won MD; Baum, Carl R. Liquid Nicotine Toxicity. Pediatric Emergency Care. 2015; 31(7): 517–521.

9. Scarpino M, Rosso T, Lanzo G, et al. Severe neurological nicotine intoxication by e-cigarette liquids: Systematic literature review. Acta Neurologica Scandinavica. 2020; 00: 1–10.

10. Takematsu, M. ACMT: What is nicotine and what forms of nicotine are available? Acmt.org. Accessed 10/8/2020.

11. Wang, B, Liu, S, and Persoskie, A. Poisoning exposure cases involving e-cigarettes and e-liquid in the United States, 2010–2018. Clin Toxicology. 2020; 58(6):488-494.

                                                  

Prepared by: Cailin Frank, DO - Pediatric Emergency Medicine Fellow, LeBonheur Children's Hospital

I am interested in any questions you would like answered in the Question of the Week.  Please email me with any suggestion at donna.seger@vumc.org.

Donna Seger, MD

Executive Director

Tennessee Poison Center

www.tnpoisoncenter.org

Poison Help Hotline: 1-800-222-1222