The Toxicology Takedown – December 2014

A 9 month old previously healthy male presents to your Emergency Department as a priority 1 code via EMS after new onset seizure activity at home.  On arrival, EMS mentions severe vomiting and tachypnea followed by seizure activity.  Vital signs are as follows: BP 153/74, HR 164, RR 48, Temp 37.6 and SpO2 87% on NRB.  CBG is 104.  As the child appears to fasciculate in front of you, you quickly reach for your Miller 1 and grab a 4-0 ETT and under RSI with atropine, etomidate and rocuronium you suction a significant amount of clear secretions from the oropharynx before passing the tube.  Breath sounds reveal diffuse rales bilaterally, O2 sats begin to rise, vitals improve and you breathe a sigh of relief.  Stepping back you note a distinct smell of apple juice on the patients clothing and skin.  EMS brings you a container the child was playing with prior to symptom onset depicted in the image.  Parents arrive shortly after and his father explains the container is from a local Vape shop.  He uses the solution in his e-cigarette in attempts to quit smoking.

  1. What are the early signs and symptoms of acute nicotine toxicity?
  1. How do we manage nicotine toxicity in the pediatric population?


Nicotine is the primary alkaloid in the plant (Nicotiana tobaccum) used for most smoking and chewing tobacco products and nicotine-like substances are found in several other plant species (betel nut, Indian tobacco, wild tree tobacco, poison hemlock, mescal bean bush, gold chain tree, and blue cohosh).  In attempts to reduce the harmful effects of cigarette use while still supplementing nicotine, nicotine gums and patches have entered the market.  Another novel nicotine delivery device is the electronic cigarette, which first entered the US market in 2007.  Also known as e-cigarettes, they are battery-powered devices that heat a liquid solution of nicotine.  The solution is vaporized so that no smoke is produced and thus, its use is sometimes referred to as “vaping”.

The main toxicologic concern with e-cigarettes is the highly concentrated nicotine solution used to refill the device.  Given the large amount of nicotine contained in small volumes, they  pose a significant toxic risk to small children. Continue reading