Intravenous and oral suicidal e-liquid poisonings with confirmed nicotine and cotinine concentrations

Sommerfeld, Karina; Łukasik-Głębocka, Magdalena; Kulza, Maksymilian; Drużdż, Artur; Panieński, Paweł; Florek, Ewa; Zielińska-Psuja, Barbara

doi:10.1016/j.forsciint.2016.03.005

Cited by 22 publications

(31 citation statements)

References 18 publications

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“…Current knowledge of e-cigarette exposures and their associated toxicity is based on case reports, small case series, and retrospective poison center data [2,3,7,[9][10][11]. Several published reports have described e-cigarette exposures causing topical irritation [8,12], GI symptoms [5,7,13,14], myocardial infarction [15], and severe nicotine toxicity manifesting as respiratory arrest [1,7,16], and even death [16][17][18][19][20][21]. Prior reports from US poison centers indicates that a large proportion of calls involve children, especially those younger than 5 years of age [2,22,23].…”

Section: Discussionmentioning

confidence: 99%

An epidemiologic and clinical description of e-cigarette toxicity

Hughes

Hendrickson

2018

Clinical Toxicology

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Introduction: E-cigarettes are battery-powered electronic nicotine delivery systems that simulate smoking by vaporizing nicotine-containing solutions. Systematic published data on e-liquid toxicity and exposures are limited to case reports and retrospective studies. Prospectively-collected data on the type of exposure, symptomatology, duration of symptoms, and concentration/flavor of e-fluids has not been published. Methods: This was a prospective observational study over a 42-month period (07/01/2014-12/31/ 2017). For all calls to a single poison center that involved e-cigarette devices or refill fluid, a data collection instrument was filled out by the specialist in poison information (SPI). Results: Two hundred sixty-five total cases were identified, including 193 children and 72 adults. The majority of both pediatric (72%; 139/193) and adult (61%; n ¼ 44/72) exposures involved e-liquid refill containers or fluid. Fifty-six percent (n ¼ 108/193) of pediatric exposures involved ingestion of refill liquid. Though children who ingested e-liquid received only a small amount, initial symptoms were evident in 32% (n ¼ 35/108) of cases. Children who did not ingest or inhale the products were less likely to develop toxicity. Only 2 children who were asymptomatic on initial call became symptomatic on follow-up. Most patients symptoms resolved within 4 hours. Seventy-one specific products/brands were identified with nicotine concentrations ranging from 0 mg/mL to 60 mg/mL with one product containing 3000 mg in a single bottle. A variety of flavors were identified, including several with names that may be attractive to toddlers or adolescents. Discussion: E-cig exposures tend to produce irritant effects from topical exposures and nicotine toxicity from ingestions, as well as some dermal and "sucking" toddler exposures. Conclusion: Exposure to e-cig fluid or device frequently causes mild symptoms and rarely may produce systemic nicotine toxicity.

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Section: Discussionmentioning

confidence: 99%

An epidemiologic and clinical description of e-cigarette toxicity

Hughes

Hendrickson

2018

Clinical Toxicology

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“…The patient had a peak blood cotinine concentration of 4,400ng/mL and survived. ( 8 ) However, blood cotinine levels ranging from 900 to 2200ng/mL have been reported in patients who died due to liquid nicotine poisoning. ( 6 - 8 ) We were not able to measure the nicotine concentration in the current patient, but the cotinine concentration measured approximately 1 hour after oral exposure was 1,296ng/mL.…”

Section: Discussionmentioning

confidence: 99%

“…( 8 ) However, blood cotinine levels ranging from 900 to 2200ng/mL have been reported in patients who died due to liquid nicotine poisoning. ( 6 - 8 ) We were not able to measure the nicotine concentration in the current patient, but the cotinine concentration measured approximately 1 hour after oral exposure was 1,296ng/mL. This value is not high compared to those reported previously; however, a few studies have shown that this amount of nicotine can be fatal if proper treatment is not provided promptly.…”

Section: Discussionmentioning

confidence: 99%

Symptomatic bradycardia due to nicotine intoxication

Paik

Kang

Durey

et al. 2018

Revista Brasileira De Terapia Intensiva

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Nicotine is a dangerous substance extracted from tobacco leaves. When nicotine is absorbed in excessive amounts, it can lead to respiratory failure and cardiac arrest. The commercialization of electronic cigarettes (e-cigarettes) has allowed users to directly handle e-cigarette liquid. Consequently, the risk of liquid nicotine exposure has increased. We describe our experience of managing the case of a patient who orally ingested a high concentration of liquid nicotine from e-cigarette liquid. The patient presented with bradycardia and hypotension, which are symptoms of parasympathetic stimulation, together with impaired consciousness. He recovered following treatment with atropine and a vasopressor.

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“…Exposure to highly concentrated substances in e-liquids through unwarranted use such as oral consumption, goes hand in hand with a substantial risk of severe toxicity [12]. Life-threatening nicotine intoxication in young children due to accidental ingestion of e-liquid has been reported [13].…”

Section: Introductionmentioning

confidence: 99%

Nicotine intoxication by e-cigarette liquids: a study of case reports and pathophysiology

Maessen

Wijnhoven

Neijzen

et al. 2019

Clinical Toxicology

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Background: Electronic cigarettes (e-cigarettes), the smokeless alternative to conventional tobacco cigarettes, have become increasingly popular. E-cigarettes vaporise e-liquid, a solution of highly concentrated nicotine, propylene glycol (PG) and vegetable glycerine (VG). With the popularity of e-cigarettes, e-liquid refills have become easily accessible and several cases of intoxication due to the ingestion of e-liquid have been reported. We provide an overview of these cases, their pathophysiology and patients' characteristics. Methods: We carried out a retrospective evaluation of the scientific literature reporting on cases of liquid nicotine intoxication, using the following inclusion criteria: (1) the article is or contains a case report, (2) describes an intoxication with e-liquid, (3) the substance contains nicotine, and (4) intake is oral, intravenous or subcutaneous. Results: We found 26 case reports describing a total of 31 patients who suffered from e-liquid intoxication. All intoxications up to the age of six were reported as unintentional, whereas nearly all cases from ages 13 to 53 were due to suicide attempts. The three most prevalent symptoms of e-liquid intoxication were tachycardia, altered mental status and vomiting. Eleven cases resulted in the death of the patient. In the survivors, the highest plasma concentration of nicotine was 800 mg L À1 , while the lowest concentration in the non-survivors was 1600 mg L À1 . Conclusions: There is a mismatch between the generally accepted lethal oral nicotine dose of 60 mg, resulting in approximately 180 mg L À1 plasma concentration, and the 4.4-to 8.9-fold higher lethal plasma concentrations we found in cases of e-liquid intoxication. In these severe intoxications, plasma cotinine concentration does not act as a more reliable indicator of nicotine intoxication than nicotine itself. The ages of the patients display a bimodal distribution. In patients above the age of 10, intoxication results mainly from suicide attempts rather than accidental ingestion. The role of PG and VG in e-liquid intoxications is remarkably unclear. However, the similarity across nicotine and PG toxicity symptoms leads us to believe a cumulative effect cannot be excluded. ARTICLE HISTORY

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Intravenous and oral suicidal e-liquid poisonings with confirmed nicotine and cotinine concentrations

Cited by 22 publications

References 18 publications

An epidemiologic and clinical description of e-cigarette toxicity

An epidemiologic and clinical description of e-cigarette toxicity

Symptomatic bradycardia due to nicotine intoxication

Nicotine intoxication by e-cigarette liquids: a study of case reports and pathophysiology

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