Acute Nicotine Poisoning

Aka: Acute Nicotine Poisoning, Nicotine Poisoning, Nicotine Toxicity, Nicotine Overdose

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II. Risk Factors

  1. High dose Nicotine exposures
    1. Smokeless Tobacco products (e-cig, Vaping)
    2. Nicotine Replacement Products (ingested patches may have prolonged exposure)
    3. Liquid Nicotine
    4. Green Tobacco Sickness (exposure to leaves in field workers, esp. wet leaves)
    5. Concentrated Nicotine Pesticides (banned in most western countries)
    6. Nicotinic Plants (Conium Maculatum, N. glauca, N. tabacum, Laburnum anagyroides, Caulophyllum thalictroides)
      1. Schep (2009) Clin Toxicol 47(8):771-81 [PubMed]
  2. Children
    1. Even low dose ingestion (e.g. 1 ml e-cig liquid refill solution) may cause toxicity symptoms in children

III. Mechanism

  1. Nicotine stimulates Acetylcholine receptors
    1. See Cholinergic Toxicity
    2. Nicotine has both sympathetic and parasympathetic effects
  2. Autonomic Ganglion blockade
    1. Occurs with higher dose exposure
    2. May result in motor weakness including respiratory arrest

IV. Findings

  1. See Cholinergic Toxicity
  2. Constitutional
    1. Diaphoresis
  3. Cardiovascular
    1. Early: Hypertension, Tachycardia
    2. Later: Hypotension, Bradycardia
  4. Respiratory
    1. Increased Bronchial Secretions
    2. Tachypnea
    3. Hypoventilation
  5. Gastrointestinal
    1. Nausea
    2. Vomiting
    3. Diarrhea
  6. Neurologic
    1. Irritability or Agitation
    2. Headache
    3. Muscle Weakness
    4. Lethargy
    5. Confusion
    6. Ataxia
    7. Seizures
      1. Onset within 2 hours of ingestion (and typically within 15-30 minutes)
    8. Paralysis
      1. Follows Seizures

V. Complications

  1. Rhabdomyolysis
  2. Respiratory Arrest
  3. Circulatory Collapse
  4. Death

VI. Labs

  1. See Unknown Ingestion
  2. Bedside Glucose
  3. Serum chemistry
    1. Serum Potassium
    2. Creatine Kinase
    3. Serum Calcium
    4. Serum Phosphorus
  4. Urinalysis

VII. Management

  1. See Unknown Ingestion
  2. ABC Management
    1. May require Mechanical Ventilation (e.g. Respiratory Failure, paralysis, severe Fasciculations)
      1. Intubate under RSI with Rocuronium (avoid Succinylcholine)
      2. Post-intubation sedation with Benzodiazepines
    2. Intravenous Fluids (20 ml/kg up to 1-2 Liter NS or LR bolus to start)
    3. Vasopressors for Hypotension
  3. Decontamination
    1. Activated Charcoal
      1. Indicated in large ingestion within last 1 hour
    2. Wash affected skin with soap and water
  4. Seizures
    1. See Status Epilepticus
    2. Benzodiazepines are primary agents
    3. Lorazepam 0.05 to 0.1 mg/kg up to 2 to 4 mg IV
  5. Anticholinergics
    1. Atropine may be used for Bradycardia and decreased secretions
    2. Consider Physostigmine

VIII. References

  1. Burns in Traub (2019) Toxic Plant Ingestions and Nicotine Poisoning in Children, UpToDate, Accessed 3/23/2021
  2. Tomaszewski (2020) Crit Dec Emerg Med 34(7):44

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