Liquid Nicotine

Vape DangerTobacco smoke is a health hazard for children (and us children of all ages).  We know this.  So it seems like movement away for cigarettes is good for everyone; however, the thirst for nicotine is still quite strong and is often satiated by electronic cigarettes (“e-cig”).  The overall safety of these devices is still to be determined, but it is important for us to realize that the kids are great at uncovering danger in almost everything (see Laundry Detergent Pods).  Let us review the potential hazard of Liquid Nicotine. {much appreciation to Dr. Christine Murphy for her expert insights!}


Childhood Poisoning

  • In the US, > 300 children / Day require treatment for poisonings. [CDC]
  • Over 50% of all ED visits for poisoning were for children <4 years of age. [Nalliah, 2014]
  • The majority of poisonings are unintentional in young children.
  • The Home is a Dangerous Place!
    • Over 90% of all toxic exposures occur in homes.
    • Liquid Nicotine exposures occur primarily in a child’s own residence. [Forrester, 2015]
    • The liquid nicotine containers are not currently sold in child proof packaging.
    • The packaging is often colorful and are often flavored – enticing to children. [Normandin, 2015]
    • Frequency of nicotine toxic exposure has increased over past several years. [Kamboj, 2016]


Liquid Nicotine: E-Cigs

  • Electronic cigarettes have been promoted as a tool for smoking cessation.
    • Primary benefit would be in reducing tobacco smoke exposure, and potentially reducing long-term sequelae.
    • Evidence shows that teenagers who have never used cigarettes now start using electronic cigarettes though (so not just a smoking cessation tool). [Lowry, 2014]
    • Acute poisoning from tobacco products is due to the nicotine.
  • Electronic cigarettes
    • E-cigs are battery-powered implements that heat a liquid solution to make vapors that are then inhaled.
    • Microprocessors detect inhalation force and trigger the heating process.
    • The liquid may contain flavors, various chemicals (ex, propylene glycol, glycerol), and liquid nicotine.
  • Liquid Nicotine
    • Formulations of liquid nicotine products vary greatly. [Forrester, 2015]
    • Nicotine concentrations range from 18mg/mL to 100mg/mL.


Nicotine Toxicity

  • Nicotine is readily absorbed through the lungs, skin, GI tract, and mucous membranes.
  • Ingestion is the most common exposure route, but can also occur by dermal, ocular, and inhalation routes.
  • Toxic Dose is not exactly know, but estimated at 1.4mg/kg.
  • Toxic Symptoms

    • Mild
      • Nausea/vomiting
        • Vomiting is the most common significant symptom (24%) [Forrester, 2015]
      • Tremors
      • Tachycardia, tachypnea, elevated blood pressure
    • Severe
      • Salivation, diaphoresis
      • Dysrhythmia, fasciculations
      • Headache, dizziness, ataxia
      • Seizures, drowsiness, coma, respiratory failure
      • Fatalities have been reported [Eggleston, 2016; Normandin, 2015]


Nicotine Toxicity Treatment

  • Airway, Breathing, Circulation, Disability, and Exposure.
  • As with all possible toxic exposures, decontamination is important.
    • Remove any soiled clothing.
    • Flush eyes for ocular exposure.
    • Rinse other areas of dermal exposure.
  • Symptomatic management is the primary strategy.
    • Be aware that seizures may present before vomiting.
    • Patients with symptoms should be observed until asymptomatic with normal vital signs.
  • Treat seizures with benzodiazepines. If intractable seizures, give more benzos, rather than anti-epileptics. [Dr. Murphy communication – of course the toxicologist would advocate for “more benzos.”]
  • While activated charcoal can absorb nicotine, it is not recommended due to the fact that onset of symptoms is rapid and often complicated by vomiting and seizures (both of which do not go well with charcoal).


Moral of the Morsel

  • If there is potential danger, kids will find it.
  • Liquid nicotine comes in attractive and enticing packaging that is not child-proofed.
  • Liquid nicotine comes is very concentrated forms.
  • Seizures may occur in severe toxic exposures even before emesis.
  • Treat seizures with benzos… and more benzos.
  • Take time to educate families about possible hazards before them become a critical event!



Eggleston W1, Nacca N2, Stork CM1, Marraffa JM1. Pediatric death after unintentional exposure to liquid nicotine for an electronic cigarette. Clin Toxicol (Phila). 2016 Jul 7:1-2. PMID: 27383772. [PubMed] [Read by QxMD]
Forrester MB1. Pediatric Exposures to Electronic Cigarettes Reported to Texas Poison Centers. J Emerg Med. 2015 Aug;49(2):136-42. PMID: 25802158. [PubMed] [Read by QxMD]

Normandin PA1, Benotti SA2. Pediatric Emergency Update: Lethality of Liquid Nicotine in E-Cigarettes. J Emerg Nurs. 2015 Jul;41(4):357-9. PMID: 25913384. [PubMed] [Read by QxMD]
Garbutt JM1, Miller W2, Dodd S2, Bobenhouse N2, Sterkel R3, Strunk RC2. Parental Use of Electronic Cigarettes. Acad Pediatr. 2015 Nov-Dec;15(6):599-604. PMID: 26306662. [PubMed] [Read by QxMD]

Collaco JM1, Drummond MB2, McGrath-Morrow SA1. Electronic cigarette use and exposure in the pediatric population. JAMA Pediatr. 2015 Feb;169(2):177-82. PMID: 25546699. [PubMed] [Read by QxMD]

Gill N1, Sangha G1, Poonai N1, Lim R1. E-Cigarette Liquid Nicotine Ingestion in a Child: Case Report and Discussion. CJEM. 2015 Nov;17(6):699-703. PMID: 25892642. [PubMed] [Read by QxMD]

Nalliah RP1, Anderson IM, Lee MK, Rampa S, Allareddy V, Allareddy V. Children in the United States make close to 200,000 emergency department visits due to poisoning each year. Pediatr Emerg Care. 2014 Jul;30(7):453-7. PMID: 24977994. [PubMed] [Read by QxMD]

The post Liquid Nicotine appeared first on Pediatric EM Morsels.

8 Tips on How to Succeed in Your EM Sub-Internship

8-Tips-Succeed-SubinternshipThis time of year is almost universally overwhelming for visiting medical students at away rotations. They are thrown into a new environment for a brief amount of time and there is a great deal of pressure to impress both faculty and residents. After years of hard work and study, these few weeks may be one of the most influential aspects of a residency application. A survey study of Emergency Medicine (EM) residency program directors by Crane et al. showed that EM rotation grade was the single most important factor in resident selection.1

Given the importance of performing well on this rotation, how do you succeed? Or equally as important, how do you NOT fail? This blog post was developed as a culmination of advice from personal experiences combined with those of the ALIEM 2015-16 Chief Resident Incubator, a network of over 200 chief residents from 71 programs across the country. While some of these tips may appear obvious, the potential anxiety associated with this high-stakes rotation causes many of these issues to still occur every month at programs across the country. Follow this advice to demonstrate your best self and avoid the problems that may easily overshadow many others.

1. Don't Be Late
2. Don't Lie
3. Be Nice
4. Don't Forget Why You're There
5. Perfect Your Presentation
6. Take Initiative
7. Have a Goal
8. Be Enthusiastic


  1. Crane JT, Ferraro CM. Selection criteria for emergency medicine residency applicants. Acad Emerg Med. 2000;7(1):54-60. PMID 10894243
  2. Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008;15(7):683-7. PMID 18691216
  3. Ander DS, Wallenstein J, Abramson JL, et al. Reporter-Interpreter-Manager-Educator (RIME) descriptive ratings as an evaluation tool in emergency medicine clerkships. J Emerg Med. 2012; 43(4):720-7. PMID 21945508

Author information

W. Gannon Sungar DO

W. Gannon Sungar DO

Staff Physician
Denver Health Medical Center
Assistant Professor
Department of Emergency Medicine
University of Colorado School of Medicine

The post 8 Tips on How to Succeed in Your EM Sub-Internship appeared first on ALiEM.

H-Ecuador is also written with H

Hola a todos, mis queridos amigos.

We are going next week to Argentina, to the 26º Congress of Argentinean Society of Intensive Care. In September, Carmen Segovia and José Carlos Igeño will go to Quito (Ecuador), to participate in the "II International Course of Evaluation and Management of the Critically ill patient".

This course will be held from September 1st to 4th and has been organized by the ICU team of Hospital Luis Gabriel Dávila, leaded by Dr. Santiago Párraga.

This amazing experience will have the participation of renowned national and international speakers national and the endorsement of the Ministry of Public Health, the University of las Americas, and the Ecuadorian Society of Intensive Care; with an academic program focused on current issues and of great interest in multidisciplinary and inclusive management of the patient, with the participation of the family, enhancing quality and humanized intensive care.

This is the program (only available in Spanish), where "the H" has a clear prominence: satisfaction, open ICU doors, the Humanization ICU Plan, counselling, grief, breaking bad news, end of life care and the process of dying. For us is an honor and pride to light the flame that #humaniza to our ecuadorian mates.

For more info and registrations:

Av. Colón 2277 y Ulloa, Edif. Fierro, 2do. Piso, Oficina 2a
(02) 2522 612 / 0998 491 937 móvil

We are so grateful and excited about this opportunity. We continue breaking the rules and opening borders, because this is a matter of all. #Benditalocura (holy madness!)

Happy Friday,

Pediatric: Ear emergencies

Pediatric: Ear emergencies

Acute otitis media (AOM)
  • พบบ่อยรองจาก URI อุบัติการณ์สูงสุดช่วงอายุ 6-18 เดือน
  • Dx
    • Moderate-severe bulging ของ TM
    • Mild bulging ของ TM + (Ear pain < 48 ชั่วโมง หรือ intense erythema ของ TM)
    • New onset of otorrhea โดยที่ไม่มี otitis externa หรือ FB
  • ถ้ามี cerumen impact อาจ remove ด้วย soft speculum หรือหยอด docusate 1 mL ทิ้งไว้ 15 นาทีแล้ว irrigate ด้วยน้ำอุ่น
  • Pain control แนะนำให้ ibuprofen 10 mg/kg PO PRN q  6 h และ paracetamol 15 mg/kg PO PRN q 4 h; อาจให้ 2% lidocaine 2-3 drops ใส่ cotton เล็กๆไว้ใน external ear canal PRN q 1-2 h (ห้ามให้ถ้ามี TM perforation)
  • ในเด็กที่สุขภาพแข็งแรง และมีอาการไม่รุนแรงพิจารณาให้สังเกตอาการ 48-72 ชั่วโมง โดยไม่ต้องให้ ATB
  • ATB แนะนำให้ใน ทารก < 6 เดือน, อาการรุนแรง (ปวดมาก เป็นนาน > 48 ชั่วโมง ไข้ > 390C), เด็ก < 2 ปีที่เป็น bilateral AOM, เป็นซ้ำใน 2-4 สัปดาห์, TM perforation หรือ myringotomy, craniofacial abnormalities, immunocompromised, หรือปฏิเสธที่จะสังเกตอาการ
  • ATB: amoxicillin 40-45 mg/kg/dose PO BID x 5-10 วัน (ถ้าเคยไม่ตอบสนองต่อ amoxicillin หรือเคยได้ภายใน 30 วัน หรือมี purulent conjunctivitis ร่วมด้วยให้ augmentin แทน), ceftriaxone 50 mg/kg IM/IV x 1-3 วัน, cefdinir 7 mg/kg/dose PO BID x 5-10 วัน, cefuroxime, cefpodoxime, clindamycin 10 mg/kg/d PO TID x 5-10 วัน; Myringotomy tube หยอด ofloxacin otic drop 5 gtts BID x 5-10 วัน
  • หลังให้ ATB จะยังมีไข้และปวดหูต่ออีก 24-48 ชั่วโมง ถ้าอาการยังคงอยู่หลัง 72 ชั่วโมง ต้องประเมินใหม่ อาจเปลี่ยน ATB เป็น augmentin หรือ ceftriaxone ถ้ายังไม่ดีขึ้นให้ consult ENT หรือให้เป็น clindamycin + ceftriaxone

Otitis media with effusion (OME)
  • ส่วนใหญ่ไม่มีอาการ อาจมีอาการปวดหูเล็กน้อยเป็นพักๆ หูอื้อ popping sensation; ตรวจจะพบ cloudy TM และมักเห็น effusion (bubbles หรือ air-fluid level)
  • Tx: ไม่ต้องรักษา ในรายที่เป็นนาน > 3 เดือน หรือทำให้เกิด hearing loss หรือ language delay ให้นัดพบ ENT

Acute otitis externa
  • Dx: ประกอบด้วยอาการ(otalgia, itching, fullness) และอาการแสดง (tragus/pinna tenderness, diffuse ear canal edema/erythema) เกิดขึ้นภายใน 48 ชั่วโมง
  • Pain control: Ibuprofen; Dry mopping ด้วย cotton-tipped wire applicator
  • Topical FU (ofloxacin, ciprofloxacin) นอนตะแคงหยอด 2-4 หยอด ขยับใบหูไปมา ทิ้งไว้ 5 นาที ในรายที่บวมมากอาจใส่ ear wick ทิ้งไว้ 3 วัน
  • ในรายที่การติดเชื้อลามไปนอก ear canal (เช่น mastoiditis, cellulitis, malignant otitis externa: fever > 38.9°C, severe otalgia +/- facial paralysis, meningeal signs) หรือเป็น immunocompromised ให้ systemic ATB (ceftazidime 50 mg/kg IV q  8 h + methicillin 50 mg/kg/dose q 6 h)
  • ถ้าอาการไม่ดีขึ้นใน 48-72 ชั่วโมง ให้พิจารณาการวินิจฉัยใหม่ งดว่ายน้ำจนกว่าจะหาย
  • ป้องกันการเป็นซ้ำ ช่วงเสี่ยง (ต้องว่ายน้ำ) ให้หยอดยาป้องกัน เช่น 2% acetic acid (VoSoL) 2-4 drop TID-QID

Acute mastoiditis
  • อุบัติการณ์สูงสุดที่อายุ 12-36 เดือน
  • มีอาการของ AOM ร่วมกับมีการบวมแดงบริเวณหลังใบหู ทำให้ใบหูกางออก อาจมี CN VI, VII palsies; ภาวะแทรกซ้อน เช่น intracranial abscess, meningitis, otitic hydrpcephalus (IICP จาก transverse sinus thrombosis)
  • Ix: CT mastoid, H/C
  • Tx: consult ENT; Piperacillin-tazobactam + vancomycin then switch to narrow spectrum

Ear FB
  • ส่วนใหญ่พบในเด็กอายุ 4-8 ปี
  • ถ้าเป็นแมลงที่ยังมีชีวิตให้หยอด mineral oil เพื่อฆ่าแมลงก่อน
  • Remove FB อาจใช้ alligator forceps, ear curette, suction, irrigation ตามความเหมาะสม
  • ถ้ามีการอักเสบหลัง remove FB ให้ topical ATB-hydrocortisone otic drop ช่วงสั้นๆ

Ref: Tintinalli ed8th