Correspondence

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American Journal of Emergency Medicine

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Incidence of electronic cigarette exposures in children skyrockets in Arizona

Electronic cigarettes, also known as e-cigarettes or e-cigs, are nicotine delivery systems that consist of a rechargeable battery, atomization chamber, and a cartridge containing a solution of nicotine, flavor, and other chemicals. E-cigarette Health effects remain largely unknown, and there are mixed reports on the efficacy of electronic cigarettes in smoking cessation [1].

Unlike cigarettes and many other tobacco products, electronic ciga- rettes are largely unregulated by the Food and Drug Administration [2]. Analyses of e-cigarette cartridge content have revealed significant variation in nicotine contents within batches (up to 12%) and between batches (up to 31%) of the same product [3]. There are also documented differences between labeled and measured nicotine concentrations in e-cig products [3]. Variable nicotine concentrations between and among electronic cigarette manufacturers and lack of product design safety standards are concerning.

From 2009 to 2012, electronic cigarettes underwent an exponential growth rate culminating in US $1.85 billion in annual sales for 2013 [4] and increased Poison Control Center (PCC) calls involving electronic cigarettes [5].

lethal doses of nicotine cause convulsions, respiratory paralysis, and death within a few minutes to 1 hour after ingestion. The estimated lethal dose is 1 to 10 mg/kg [6]. For the average 10-kg toddler, this is far exceeded in a typical e-cig. Concentrations of nicotine in e-liquids are typically 2.4% to 3.2% (24-32 mg/mL) but can be as high as 10% (100 mg/mL) [7]. A typical e-cigarette contains 1 to 3 mL of e-liquid or up to 72 mg of nicotine [7], enough to kill a 10-kg toddler. A 30-mL refill e-liquid vial of 2.4% contains 720 mg of nicotine with much greater lethal potential.

We conducted a retrospective medical record review of electronic cigarette exposure calls to the PCC to evaluate trends in exposures over time and patient demographics and further characterize outcomes following electronic cigarette exposure.

To characterize outcomes of electronic cigarette toxicity, we con- ducted a retrospective medical record review. Data from cases of elec- tronic cigarette exposures called into the PCC between January 1,

2012, and December 31, 2014, were used for analysis. The Arizona Poison Control Center receives approximately 100 000 human exposure calls annually. Inclusion criteria for the study were cases of self- or surrogate-reported exposure to electronic cigarettes to the Arizona PCC. Exclusion criteria included confirmed nonexposures, miscoded cases, and multiple agent exposures involving electronic cigarettes.

At the time of call, data for each case were collected by poison infor- mation specialists and medical toxicologists on staff. Data collected in- cluded case number, age, sex, vital signs, intent, offending agent(s), medication(s), dosage, laboratory values, interventions, and outcomes. All patients were followed until the cessation of symptoms or were evaluated at a 1-hour telephone follow-up if asymptomatic (Fig. 1).

After institutional review board approval, each case was deidentified and data were extracted by a member of the research team. The reviewer underwent standard training for manual, systematic medical record re- view prior to data extraction. Reports of electronic cigarette exposures were retrospectively queried using the Crystals Reports search engine. A master list of unique subject numbers assigned to each medical record was generated. The data were collected into a predesigned data abstrac- tion form and then entered into an EXCEL spreadsheet. The collected data were secured in password-protected electronic computer files. Extracted data included case number, date of call, age, sex, confounders or other potential reasons for the patient’s symptoms, clinical effects, hospital referral, treatments received, and outcomes. Outcomes were de- fined as development of symptoms, abnormal laboratory values, man- agement site, hospital admission, and death. Normal and abnormal laboratory values were based on our institutional definitions. The pediatric population was defined as not older than 5 years. Ten percent of cases were reviewed by a second investigator to ensure reliability of data extraction from PCC medical records.

Descriptive statistics were used with continuous variables and re-

ported as means with standard deviations. Categorical variables and outcomes were reported as case numbers and percentages.

During the study period, 100 patients met the inclusion criteria. Electronic cigarette exposure calls to our PCC have increased annually, with 10 total reported exposures in 2012, 24 in 2013, and 66 in 2014

(Fig. 2, Table).

Fig. 1. PCC exposure processing.

0735-6757/(C) 2015

Fig. 2. Annual exposures reported to Arizona PCC in children not older than 5 years.

Children not older than 5 years accounted for 52.0% of total exposure calls (range, 40.0%-54.2%). The high exposure reports for this age group are consistent across all years assessed, with children not older than 5 years accounting for 40.0% of total exposures in 2012, 54.2% in 2013, and 53.0% in 2014. Electronic cigarette exposures increased by 775% for children between 2012 and 2014 compared to a 417% increase observed in adults over that same time period.

All patients were asymptomatic or reported mild symptoms including vomiting, nausea, and dizziness. All symptomatic patients were evaluated in the hospital and discharged. In 2014, the majority of patients were asymptomatic following exposure (95.4%); however, those who exhibi- ted symptoms were all children younger than 5 years.

We found that children younger than 5 years also experienced a greater increase in electronic cigarette exposure cases (775%) from 2012 to 2014 compared to adults (417%) in Arizona.

It is surprising that electronic cigarette exposures were only asso- ciated with minimal adverse effects in our study, limited to nausea, vomiting, and dizziness. Dose information was not obtained, so the mild clinical symptoms may reflect low exposure doses. However, our findings of mild symptomatology are consistent with other published reports [5].

Case reports have identified more serious potential health effects of e-cigarette exposure, including Paroxysmal atrial fibrillation, lipoid pneumonia, and subacute bronchial toxicity [8-10]. Tragically, December 2014 marked the first child fatality attributed to electronic cigarette toxicity. A 1-year-old New York child was found unresponsive approxi- mately 2 hours after consuming bubblegum-flavored e-liquid [11].

Our study was limited by several factors. Electronic cigarette expo- sures were likely underestimated because of the passive surveillance system within the Arizona PCC that is dependent on self- or surrogate exposure reports. There is also potential for reporting bias in unreported electronic cigarette exposures or patients whose history was unknown.

Table

Annual exposures reported to Arizona PCC

The higher exposure rates in children may have been a consequence of higher overall reporting rates in children than in adults.

Frank LoVecchio, DO, MPH

Banner Good Samaritan Poison and Drug Information Center

CTPER, Phoenix, AZ 85006, USA

Maricopa Integrated Health System, Emergency Department

Phoenix, AZ 85008, USA University of Arizona College of Medicine, Phoenix

Phoenix, AZ 85006, USA

Corresponding author

E-mail address: [email protected]

Olivia Zoph

University of Arizona College of Medicine, Phoenix

Phoenix, AZ 85006, USA

http://dx.doi.org/10.1016/j.ajem.2015.02.036

References

1. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev 2014;12:CD010216. http://dx. doi.org/10.1002/14651858.CD010216.pub2 [Epub 2014 Dec 17].
2. Food and Drug Administration. News and events-electronic cigarettes (e- cigarettes). Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2014 [Available at http://www.fda.gov/newsevents/ publichealthfocus/ucm172906.htm].
3. Goniewicz ML, Hajek P, McRobbie H. Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications. Addiction 2014;109(3):500-7.
4. Yanzhong Huang. E-cigarettes: China’s next growth industry. The Council on Foreign Relations; 2014 [Available at http://blogs.cfr.org/asia/2014/05/27/e-cigarettes- chinas-next-growth-industry/].
5. Vakkalanka JP, Hardison Jr LS, Holstege CP. Epidemiological trends in electronic cigarette exposures reported to U.S. poison centers. Clin Toxicol (Phila) 2014;52(5):542-8.
6. Baselt RC. Disposition of toxic drugs and chemicals in man. Nicotine. 7th ed. Forester City (CA): Biomedical Publications; 2004. p. 785-7.
7. Glantz S. Child resistant packaging of electronic cigarette devices and refill liquid containers containing nicotine to prevent childhood. The California Poision Control System based at San Francisco General Hospital; 2014.
8. Hureaux J, Drouet M, Urban T. A case report of subacute bronchial toxicity induced by an electronic cigarette. Thorax 2014;69:596-7.
9. McCauley L, Markin C, Hosmer D. An unexpected consequence of electronic cigarette

   use. Chest 2012;141(4):1110-3.

   Monroy AE, Hommel E, Smith ST, Raji M. Paroxysmal atrial fibrillation following electronic cigarette use in an Elderly woman. Clin Geriatr 2012;20:28-32.

10. Lindahl D. NYPD confirms a year old child died after intake of liquid nicotine used in e-cigarettes. The Westside Story; 2014 [Available at http://thewestsidestory.net/ 2014/12/14/24745/nypd-confirms-year-old-child-died-intake-liquid-nicotine- used-e-cigarettes/].

    Further consideration in evaluation of Right ventricular infarction

    

    To the Editor,

    We read with great pleasure the interesting report by Aiman et al [1]. The proposed hypothesis of vasospasm of isolated right-sided coronary arteries is appealing and well possible; however, other relevant consid- erations should be entertained especially in the absence of objective ev- idence of vasospasm during coronary angiography. Because the patient was unresponsive, hypotensive, and acidotic, concomitant significant hypoxia is presumably highly likely. Patients with hypoxic respiratory failure or even drug overdose can manifest as transient right ventricular dysfunction and also frequently with biventricular dysfunction [2]. Again, elevated pulmonary artery pressures and pulmonary vascular re- sistance may be explained in this setting by associated hypoxia-related pulmonary vasoconstriction and mild left ventricular dysfunction resulting in the elevation of wedge pressures.