Electronic cigarettes have been gaining popularity in the U.S. as a smokeless delivery system for nicotine. These devices require liquid nicotine (e-liquid) that are vaporized and inhaled (vaping).

E-liquid can have nicotine concentration as high as 100 mg/mL, which are diluted prior to use. When ingested in high concentration and in sufficient volume (1 vial = 15 mL) patients can develop significant nicotinic toxicity. Recently a case of cardiac arrest has been reported after ingesting two 15 ml vial (100 mg/mL).

Nicotine mimics the effects of acetylcholine (Ach) release by binding to nicotinic receptors located in:

Brain

Spinal cord

Autonomic ganglia

Adrenal medulla

Neuromuscular junction

Chemoreceptors of carotid/aortic bodies

Clinical manifestation of toxicity (similar to cholinergic toxidrome) is biphasic with early central stimulation followed by depression. (see table below)

GI Respiratory Cardiovascular Neurologic Early (1 hr) Nausea Vomiting Salivation Abdominal pain Bronchorrhea Hyperpnea Hypertension Tachycardia Pallor Agitation Anxiety Dizziness Blurred vision Headache Hyperactivity Tremors Fasciculation Seizures Late (0.5-4 hr) Diarrhea Hypoventilation Apnea Bradycardia Hypotension Dysrhythmias Shock Lethargy Weakness Paralysis

Management: There is no specific antidote or reversal agent. The management of nicotine toxicity focuses on organ-specific dysfunction.

e.g. bronchorrhea = atropine; apnea = intubation; seizure = benzodiazepine.

References