Electronic cigarettes continue to rise in popularity as a reportedly safe alternative to standard cigarette smoking. Their use has become common in our society and specifically in our young active duty population. This cigarette smoking alternative has come under recent scrutiny with the discovery of e-cigarette or vaping product use-associated lung injury. However, there is another potential risk associated with vaping: the relative ease at which vaping devices can be modified has allowed a growing community of users to invent novel ways of delivering higher concentrations of nicotine. Here, we describe two cases of active duty patients who presented to an emergency department with clinical nicotine toxicity after using a heavily modified e-cigarette.
Plant extracts and other novel psychoactives can be ingested, vaped, injected, or insufflated. This includes products such as extracts from the blue lotus flower (Nypmhaea caerulea), which is known to produce euphoria and hallucinations at high doses. Blue lotus is sold in several forms, including dried plant material, teas, and extracts for use in electronic cigarettes. Because newer generations of electronic cigarettes can deliver a variety of substances, practitioners need to be mindful of toxicity from a growing number of psychoactives, some of which are not detectable by standard urine drug screens. This case series describes five active duty patients who presented to the emergency department with altered mental status following the use of blue lotus products, four after vaping and one after making an infused beverage. Patients displayed similar symptoms, including sedation and perceptual disturbances. The patients in our series were successfully managed with supportive measures without the need for sedating agents. Recognizing and identifying new trends in substance use can help to provide directions in undifferentiated altered mental status.
Mediastinal masses are a rare finding in the emergency department and typically present with vague chest complaints such as chest discomfort, chest pain, or dyspnea. Rarely do these tumors present with dysrhythmias, and when dysrhythmias are present, they typically arise secondary to endocrine or metabolic effects exerted by the tumor. Here we report a case of a patient who presented to the emergency department with atrial fibrillation with rapid ventricular response, concomitant with a history of recurrent palpitations that were previously aborted with self-induced vagal maneuvers. Upon further investigation, the patient had an anterior mediastinal mass, diagnosed as a thymoma, suspected to be contributing to his presenting dysrhythmia through mass effect.
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