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Nicotine toxicity

Protecting children from e-cigarette exposure

Quail, M. Thomas MSEd, RN, LNC

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doi: 10.1097/01.NURSE.0000615084.47597.14
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Figure

CHILDREN AGES 5 years and younger account for more than 60% of nicotine-related calls to poison control centers as a result of exposure to e-cigarette devices and nicotine products.1-4 Compared with children exposed to traditional cigarettes, those exposed to nicotine products used in e-cigarettes are 5.2 times more likely to be admitted to a healthcare facility and 2.6 times more likely to experience a severe outcome.3,5

This article reviews the risk of toxicity in children accidentally exposed to nicotine solutions from e-cigarettes and discusses the appropriate nursing interventions.

About e-cigarettes

In the US, marketing efforts for e-cigarette devices and nicotine products began in 2006.2,6 The devices include a tube for inhalation, a reservoir to store the nicotine solution, and a battery component to heat it.2,6,7 Closed reservoirs hold a prefilled nicotine cartridge; open reservoirs are refillable.

The prefilled cartridges carry 5 mL of solution and may contain between 6 mg/mL and 62 mg/mL of nicotine.2,6,8,9 Approximately 1 mL of 24 mg/mL liquid is equivalent to a pack of 20 cigarettes.10 Bottled solutions used for refillable devices may contain between 100 mg and 500 mg of nicotine and vary in volume from 5 mL to 30 mL.4,9 Solutions are typically mixed with a vegetable glycerin, propylene glycol, and nicotine.2,6,9,11 These are available in thousands of flavors and packaged with brightly colored labels, which may be attractive to children.2,6,9,11 Some solutions are labeled “nicotine-free,” but they may still contain small amounts of nicotine.9,11

Since the introduction of e-cigarette devices, the American Academy of Poison Control Centers (AAPCC) has reported an increase in call volume (see Exposures to e-cigarettes). Although all age groups were affected, children ages 5 years and younger accounted for more than 60% of nicotine-related calls from accidental exposure.1-4 One study reported that “the potential for toxic exposure among young children is heightened by the lack of regulation and standardization of nicotine concentration in e-cigarette cartridges and refill solutions.”3 (See Surveillance efforts.)

Understanding nicotine toxicity

Nicotine is a highly toxic alkaloid that has neurotoxic effects on brain development and chemistry.7,12 It binds to the nicotinic cholinergic receptors, acting as an agonist at nicotinic-type acetylcholine receptors. A lethal dose is estimated to range from 0.8 mg/kg to 13 mg/kg.1,2,5,7 Toxicity is dose-dependent, however, and as little as 2 mg of nicotine has caused toxicity in pediatric patients.2,7,10,12,13

Nicotine is rapidly absorbed through the skin, oral mucosa, and gastrointestinal (GI) and respiratory tracts, with a 70% to 90% first-pass effect.2,8,12 Additionally, nicotine can easily cross the placental barrier and be present in both amniotic fluid and breast milk. It is rapidly metabolized, with a half-life of 120 minutes, and is excreted in the urine.7,12,14

Table
Table:
Exposures to e-cigarettes15,16

E-cigarettes are designed to heat the nicotine solution, producing a vapor that contains harmful toxins and carcinogens such as acetaldehyde, acrolein, and formaldehyde. This vapor may also contain other substances, including aerosolized particulates, aldehydes, carbonyls, metals, polycyclic aromatic hydrocarbons, tobacco-specific nitrosamines, and volatile organic compounds.2,6,7 Children and other nonusers are at risk for inhaling the vapors. Additionally, thirdhand residual aerosols remain on surfaces and may react to oxidants in the environment, causing potentially harmful nicotine exposure.12 (See Case reports.)

Signs and symptoms

Understanding the immediate signs and symptoms of nicotine toxicity is crucial and factors into appropriate first aid measures. The early signs and symptoms may include nausea, pallor, dizziness, diaphoresis, and vomiting. Vomiting helps reduce nicotine absorption. Other possible signs and symptoms may include abdominal pain, excessive salivation, bronchorrhea, hypertension, and tachycardia. Most resolve within 1 to 2 hours, but delayed onset and prolonged effects may occur with higher doses of absorption. In these cases, nicotine can cause bradycardia, dyspnea, hypotension, seizures, and respiratory failure, which may be fatal.2,3,6,12

Children exposed to e-cigarette nicotine solutions or products often present with multiple symptoms, but fatal adverse reactions are rare. Compared with those exposed to nicotine from cigarettes, however, children who have been exposed to nicotine solutions from e-cigarettes are at an increased risk for admission to a healthcare facility and poor outcomes.3,5

Treatment and nursing care

In cases of suspected nicotine poisoning, assess and support the ABCs and make airway protection a priority due to the potential for vomiting and aspiration. Question the patient and/or caregivers to gather details about the incident. For example:

  • Did the caregiver witness the child's exposure to the product?
  • Did the child have enough time to pick up the product, open the container, and become exposed?
  • Does the child's breath smell like the product?
  • Is the child's mouth the color of the product?
  • Is the child symptomatic?
  • Could any other children have been exposed?
  • What is the concentration of the nicotine solution?
  • What is the child's weight?

Patients with developmental issues and intellectual disabilities are considered high-risk and may become exposed to a greater quantity of product.12 A poison control center should be contacted to assist caregivers and healthcare professionals to determine if the exposure was poisonous and recommend treatment.

Treatment is determined based on how much of the product was available, how much is left, how much was spilled, and the patient's signs and symptoms.2,12 The management of nicotine toxicity is symptomatic, supportive, and may include observation and I.V. fluids. Endotracheal intubation and mechanical ventilation may be utilized with higher doses. Depending on the patient's clinical status, providers may prescribe medication to control bronchorrhea, emesis, and seizures.2,12

Activated charcoal is often contra-indicated due to nicotine's emetic effects and the risk of aspirating the charcoal. However, it may be recommended if concomitant substances are ingested. Lavage may be indicated, especially when large quantities of nicotine solution have been ingested.12

Healthcare professionals should weigh the risks and benefits of different treatments. Consultation with a toxicologist is highly recommended by calling the National Poison Help Hotline at 1-800-222-1222.

Preventing exposures

Children ages 5 years and younger are susceptible to poisoning because they are very inquisitive and regularly place items in their mouths. The more safety precautions in place at home, the less likely a child will be exposed. Educate parents to keep toxic substances out of a child's reach, in the original container, and stored properly. By incorporating effective prevention strategies, such as safe handling techniques, childproof packaging, and easy access to contact information for emergency poison control centers, they can help ensure a safe home environment.

Surveillance efforts1,4,15,17,18

In 2014, the AAPCC began surveillance on six new e-cigarette product categories to document exposure, the associated signs and symptoms, hospital admissions, treatment options, and patient outcomes. These included e-cigarette nicotine devices with unknown or added flavors, those without added flavors, those with unknown or added liquid flavors, and those without added liquid flavors.

The Child Nicotine Poisoning Prevention Act of 2015 was signed into law as a result of a child fatality. It requires e-cigarette manufacturers to comply with the special packaging laws, childproofing contents in accordance with the standards as outlined in the Poison Prevention Packaging Act of 1970 to reduce the risk of poisoning. However, it does not restrict the sale of highly concentrated nicotine solutions.

Case reports

The following case reports from around the world illustrate the dangers of e-cigarette nicotine solutions.

  • In the US, the first report of e-cigarette nicotine poisoning in a pediatric patient was a 10-month-old male. He ingested an unknown amount of e-cigarette refillable fluid, which contained 18 mg/mL nicotine. His signs included vomiting, tachycardia, grunting respirations, and truncal ataxia. He was discharged 6 hours postexposure, and the treatment provided is unknown.19
  • In the first suspected pregnancy-related health effect associated with excessive e-cigarette usage, the mother had been using one 30 to 50 times daily during pregnancy. The male infant presented with abdominal distension and respiratory distress 1 day after a normal delivery. An abdominal X-ray revealed extensive pneumatosis intestinalis. He was placed on broad-spectrum antibiotics. He had multiple surgeries for GI bleeding, mucosal erosion, and large intestine stricture but later made a full recovery.20
  • A 2-year-old girl was suspected of ingesting an unknown amount of nicotine from a grape-flavored e-cigarette refillable bottle. The nicotine concentration was 24 mg/mL. The patient had purple-colored lips, indicating that she drank the grape-flavored liquid, a wet shirt, and the odor of the product on her breath. She vomited at home multiple times. On the way to the ED, she was irritable and continued to vomit. Approximately 30 minutes postexposure, she slowly returned to baseline, was able to take fluids, and was monitored for several hours in the ED without further incident before discharge.21
  • A 6-year-old girl was inadvertently administered 10 mL of a nicotine solution that was improperly stored in a children's ibuprofen container. The nicotine concentration was 60 mg/mL. Within minutes, she became unconscious and began experiencing jerking movements of all extremities. She arrived at the ED approximately 25 minutes postexposure, and her mental status fluctuated between agitation and unresponsiveness. She remained stable on mechanical ventilator support overnight, was extubated the following day, and was discharged 3 days postingestion.22
  • A toddler age 18 months ingested an unknown amount of a concentrated e-cigarette liquid (100 mg/mL). Within minutes, he began vomiting and had a seizure. When emergency medical services arrived, he was unresponsive, apneic, and pulseless, and CPR was initiated immediately. The child arrived at the ED approximately 60 minutes postingestion, where CPR continued for an additional 90 minutes without success. As a result of this case, the Child Nicotine Poisoning Prevention Act of 2015 was signed into law.1
  • Another toddler, age 15 months, died after ingesting 5 mL of liquid nicotine with a concentration of 10 mg/mL. Immediately after the exposure, she vomited and became unresponsive. Computed tomography of the head revealed severe cerebral edema, and an electroencephalogram showed diffuse cerebral dysfunction. Despite aggressive supportive care, she continued to decline. She was declared brain-dead on day 43 and was removed from life support the following day.23

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    Keywords:

    e-cigarettes; nicotine toxicity; pediatrics; poison control

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