Content uploaded by Giuseppe Lippi
Author content
All content in this area was uploaded by Giuseppe Lippi on Nov 10, 2014
Content may be subject to copyright.
A preview of the PDF is not available
Bad news about an old poison. A case of nicotine poisoning due to both ingestion and injection of the content of an electronic cigarette refill
Abstract
There are increasing concerns about the escalating use of electronic cigarettes (e-cigarettes). In particular, smokers have been advised by important agencies such as the US Food and Drug Administration about the potential harm to the health of these products, being now considered as drug delivery devices. The leading issues supporting this statement include the repeated inhalation of propylene glycol that is used as a diluent in refills, accidental poisoning, as well as evidence that ecigarettes may promote continued smoking since their use may compromise quitting motivations. Some authors have minimized these risks, considering the potential advantages of these devices for public health. Here we describe the first case of nicotine poisoning due to both ingestion and intravenous injection of the content of an e-cigarette refill, incorrectly mixed with methadone, bottled in a generic vial.
... This represents the first case of evolution toward BD after nicotine intoxication occurring in Italy and related exclusively to oral ingestion F I G U R E 1 Plasmatic concentration of nicotine and cotinine measured by LC/MS-MS technique of e-liquid. In the only previous reported Italian case (Cervellin, Luci, & Bellini, 2013), in fact the patient mixed e-liquid with methadone and took the solution both orally and intravenously. ...
Background
The use of electronic cigarettes (e‐cigarettes) is very common worldwide. To date, an increase of nicotine intoxication following an accidental or intentional ingestion/injection of refill solution (e‐liquid) has been detected.
Case
A 23‐year‐old man presented with sudden loss of consciousness, bradycardia, and respiratory muscle paralysis after intentional ingestion of e‐liquid. Early clinical data, brain computed tomography, and neurophysiological tests (electroencephalogram [EEG] and somatosensory evoked potentials [SEPs]) did not show features with a poor neurological prognostic meaning of an hypoxic encephalopathy. After 4 days, the patient showed bilateral loss of the pupillary reflex, and severe and cytotoxic edema was detected on brain magnetic resonance imaging. SEPs showed a bilateral loss of cortical responses and EEG a suppressed pattern. Nine days after the onset of coma, the patient evolved toward brain death (BD).
Discussion
Because nicotine intoxication might cause respiratory muscle paralysis, without cardiac arrest (CA), it would be important to understand the mechanisms underlying brain damage and to take into account that the current neurological prognostic evidence for hypoxic–ischemic encephalopathy, based on data from patients who all experienced CA may not be reliable. Reporting cases of nicotine intoxication through e‐liquid is relevant in order to improve regulatory parameters for e‐liquid sale.
... Poisonings were caused by accidental (9/28) [138][139][140][141][142][143][144][145][146] or intentional ingestion (14/28) [147][148][149][150][151][152][153][154][155][156][157][158] of e-liquid, intravenous injection of e-liquid (4/28) [151,[159][160][161], or both ingestion and injection (1/28) [162]. ...
Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016–2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.
... Poisonings were caused by accidental (9/28) [138][139][140][141][142][143][144][145][146] or intentional ingestion (14/28) [147][148][149][150][151][152][153][154][155][156][157][158] of e-liquid, intravenous injection of e-liquid (4/28) [151,[159][160][161], or both ingestion and injection (1/28) [162]. ...
Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016–2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.
... In our case, the diagnosis was confirmed by the clear medical history described by the parents. Several modes of voluntary or accidental poisoning with nicotine have also been reported : Oral self-administration or intravenous injection of nicotine solution or nicotine liquid used in electronic cigarettes; The application of transdermal patches containing nicotine; The ingestion of nicotine pesticides, as well as swallowing or accidental ingestion of tobacco or tobacco products by children; Ingestion of boiled tobacco water used enemas for intestinal parasites [7][8][9]. The dermal absorption of nicotine has also been reported after spraying or applying insecticides containing nicotine to skin or clothing and during contact with tobacco leaves in the workplace [10]. ...
Acute intoxication with nicotine is possible to cause nonspecific clinical signs and may be serious and lead to the death. We report a rare and severe form of acute nicotine poisoning secondary to dermal absorption of tobacco.
Electronic cigarettes are devices that produce an aerosol by heating e-liquid. Their history can be traced back to the 20th century but their popularity exponentially increased in the 21st century. Multiple generations and types of e-cigarettes are available on the market with an astounding choice of e-liquids. They gained popularity in almost all countries and among all age groups. The regulation concerning them varies drastically across the world. The health impact is still not fully understood. Although e-cigarettes contain less toxic substances compared to regular cigarettes their use is still not harmless. Some studies suggest a correlation between e-cigarettes and cardiovascular diseases and a potential cancer risk. However, the most noticeable is the effect on the respiratory system. There have been reported cases of fatal respiratory failure caused by e-cigarette use. There has been an increased interest in using e-cigarettes for recreational drug use, notably cannabinoids. E-liquids have been used in suicide attempts. They are usually ingested causing potentially lethal poisoning. Furthermore, lung biopsy and extensive medical history analysis should be the cornerstone of forensic examination of deaths involving e-cigarettes.
The purpose of this article is to present selected women’s narratives from the agricultural periphery of Upper Silesia – the Hlučín region. The author focuses on the works of Eva Tvrdá and Anna Malchárková, their self-positioning, the way they tell their stories, and the common elements in their narratives about indigenous women. Local women had faced multifaceted discrimination throughout the 20th century – partly
based on ethnicity and faith, partly based on gender. Raised in a patriarchal culture, they were subjected to its patterns and replicated them. Still, their position vis-à-vis men was ambivalent – they were able to take over their responsibilities, and they also wanted to decide about their reproductive work. Significant for the protagonists of the analyzed texts is their bond with the land, rediscovered by their female descendants.
The granddaughters, however, partially change the patterns their grandmothers and mothers developed, breaking the circle of silence and quiet acceptance of their own fate.
Purpose: Acute nicotine poisoning by liquid nicotine in electronic cigarettes is becoming an increasing problem worldwide. The current systematic review aimed to determine the harm of acute nicotine poisoning by reviewing published case reports. Methods: An online literature search with PubMed, Embase, Cochrane Library, and KoreaMed database was performed to identify relevant studies addressing acute nicotine poisoning with electronic cigarettes. Two investigators searched the case reports written in English or Korean. Results: Twenty-six cases were included in this study. The routes of intoxication included ingestion in 18 cases, intravenous injection in three cases, subcutaneous injection in two cases, and ocular exposure in two cases. Ten cases had a cardiac arrest, and seven of them died. Seven out of 12 cases with intentional poisoning had a cardiac arrest. Nine children under 18 years were reported, and three of them had a cardiac arrest. Sixteen cases without a cardiac arrest recovered well, except for one case with sudden sensorineural hearing loss. Conclusion: The authors reviewed the risks of electronic cigarette liquid in terms of acute poisoning through a systematic review. The nicotine solution of an e-cigarette can be life-threatening in cases of acute poisoning. Therefore, active emergency treatment with early recognition is necessary. In addition, various management methods and regulations for preventing acute nicotine poisoning, such as restriction of distribution and nicotine concentration, should be considered.
Electronic cigarettes (e-cigarettes) is relatively recently introduced to the market. Its long-term effects are still unclear and require years of research. On the other hand, knowledge about the short-term effects of e-cigarettes is emerging. The purpose of this review was to examine the current literature on the acute health consequences associated with the e-cigarette. We used pre-specified keywords to conduct searches in academic databases of articles published between 2011 and 2020. This review focused on acute health consequences of e-cigarettes in humans that can be directly attributed to the e-cigarette. Burns and injuries associated with device explosion, e-liquid intoxication, e-cigarette or vaping product use-associated lung injury, and pneumomediastinum were identified as acute health consequences associated with e-cigarettes. Except for pneumomediastinum, these acute health consequences are unique to an e-cigarette that are unlikely to be caused by a conventional cigarette. In the short term, the e-cigarette is likely more harmful than the conventional cigarette. Tightening safety regulations on the manufacturing, distribution, and sale of e-cigarette devices is recommended. Compulsory child-resistant containers for e-liquid containers, banning or restriction the use of colorful labels on e-liquid containers, and compulsory warning labels on e-liquid containers are recommended to prevent child’s ingestion of e-liquid.
Electronic cigarettes are a popular, easily purchased, alternative source of nicotine that is considered safer than conventional tobacco. However, Intentional or accidental exposure to e‐liquid substances, mainly nicotine, can lead to serious, potentially fatal toxicity. Emergency and critical care physicians should keep in mind acute intoxication of this poison with a biphasic toxic syndrome. We highlight its potentially fatal outcome and suggest monitoring the adverse effects of nicotine according to a multimodal protocol integrating somatosensory evoked potentials, electroencephalography and neuroimaging data with anamnestic report and toxicological and laboratory data.
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 µg L⁻¹, while the lowest concentration in the non-survivors was 1600 µg L⁻¹.
Conclusions: There is a mismatch between the generally accepted lethal oral nicotine dose of 60 mg, resulting in approximately 180 µg L⁻¹ 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.
The perceived threat of terrorism has persuaded people to accept more and more constraints on their liberties. Airline passengers must partially undress before passing through a metal detector. They must remove from their hand luggage anything appearing on a long list of prohibited items ranging from the obvious (e.g. dynamite) to the bizarre (e.g. snow globes). They accepted, reluctantly, the confiscation of vast amounts of toiletries condemned for failing to fit in an arbitrarily sized plastic bag. In some countries they accept that their communications will be intercepted and they will be followed by closed circuit television cameras. The amateur physicists and biologists among them understand that, should they want to purchase some uranium or ricin for experiments at home, they will be unable to.
The justification for these constraints is the need to take any measure that might possibly reduce the risk of …
Inhalation of smoke from burning tobacco remains the most deadly risky behavior in the United States. For years, corporations have sought alternative methods to administer nicotine to the brain without the harms of combustion while retaining the immediate rewarding aspects of cigarettes that make them so profitable, pleasurable, and addictive. The latest attempt at reduced harm products is a heterogeneous collection of battery-driven inhalers termed by the World Health Organization (WHO) as electronic nicotine delivery systems (ENDS)1 or more popularly as electronic cigarettes or e-cigarettes. These devices pose significant challenges to the public health community because their distribution and use has become widespread in the United States while simultaneously evading most regulatory structures. Ultimately, these devices force a close consideration of how the health and regulatory system evaluates claims of safety and harm reduction in a dynamic, consumer driven environment to ensure the broad protection of public health.
A 27-year-old female nurse intravenously injected 5 mL of cigarette soakage solution that contained approximately 5.7 mg nicotine, in a suicidal attempt. Clinical manifestations consisted of nausea, palpitation, abdominal pain, repeated vomiting, and diarrhea. She remained fully conscious during this episode. About 7 hours later, she visited emergency department on foot and received fluid infusion for dehydration. She fully recovered at night of the day. This is the first documented report of acute nicotine poisoning due to intravenous injection of cigarette soakage in humans. Signs and symptoms appeared immediately after the injection, but this case seemed to be relatively mild in terms of clinical manifestation. The elimination half-life of nicotine seems to be short, that is, less than 1 hour. Therefore, if initial treatment is appropriate and the patient can survive acute phase of nicotine poisoning, prognosis is good.
A fatal case of multidrug poisoning by tramadol and nicotine is reported. Tramadol is a centrally acting analgesic used in the treatment of moderate to severe acute or chronic pain. Nicotine, a lipid-soluble alkaloid, is one of the most readily available drugs in modern society. A 46-year-old man was found dead in his bed, and a suicide note was discovered near the body. He had 25 transdermal nicotine patches attached to his thorax and abdomen. Two half emptied bottles were found on the bedside table; the toxicological examination revealed that they contained tobacco and nicotine as well as other drugs such as diphenhydramine. At autopsy, areas of fresh and old myocardial infarction as well as diffuse pulmonary congestion and edema were present. The tramadol concentration was 6.6 microg/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0 microg/mL in femoral venous blood. Based on these results, we determined the cause of death to be cardiorespiratory failure induced by the additive effects of tramadol and nicotine shortly after consumption.
Severe nicotine intoxication occurred in a patient after ingestion of a tobacco extract made from a recipe found on a freely available Internet site.
To determine the levels of nicotine and cotinine in the plasma of a patient who tried to commit suicide by drinking a highly concentrated tobacco extract.
A 67-year-old man tried to commit suicide by following guidelines found on an Internet site. He soaked 300 grams of tobacco for 3 days in water, evaporated most of the extract, and drank the rest of it. He felt sick immediately, with the following signs: respiratory depression, hypothermia, hypersalivation, bradycardia, and myoclonic jerks. Soon after the ingestion he vomited most of the extract. Toxicological analysis revealed potentially life-threatening nicotine and cotinine serum concentrations. Surprisingly, nicotine peak levels (322 microg/L) and cotinine peak levels (9092 microg/L) were reached more than 3 h after ingestion of the extract. Estimated nicotine and cotinine half-lives were 200 min and 1185 min, respectively. Treatment consisted of gastric lavage, ventilation, and monitoring of vital functions. The patient recovered and was discharged from the Emergency Department 4 days later without sequelae.
Nicotinergic intoxication is not always easy to recognize, and without clues from the patient and the toxicologic analysis, might well have been missed in the present case.
A fatal case of nicotine poisoning is reported in which a 44-year-old female committed suicide in a short time by taking orally the eluate from tobacco. External examination showed no abnormal findings except for markedly dark red-purple postmortem lividity, and internal examination demonstrated no pathological changes but the signs of sudden death. Through the toxicological investigation by GC and GC-MS, however, nicotine was detected in the solution which she had taken orally and in the blood, urine and the contents of the stomach and small intestine. The nicotine concentrations of the blood, urine and contents of stomach and small intestine were 6.3 micrograms/ml, 1.5 micrograms/ml, 30 micrograms/ml and 71 micrograms/g respectively, and enough to be lethal.
Nicotine is one of the most readily available and commonly abused drugs in modern society. However, serious or fatal overdoses of this agent are rare. We present a case of intentional fatal ingestion of nicotine alkaloid solution. This diagnosis may be elusive since nicotine is commonly qualitatively identified on urine toxicology screens, but is seldom quantified. Clinicians should be knowledgeable about the nature of this agent and its pathophysiologic presentations since recognition of the toxidrome is often necessary to make this diagnosis.