Nicotine Poisoning

Nicotine-2D-skeletal[1]

Nicotine (C10H14N2), a naturally occurring alkaloid is a Solanaceae family member, which also house tobacco, tomato, green pepper, potato and eggplant. It was first isolated and identified as a major component of tobacco plant in 1828 [1]. Cigarettes, cigars, other tobacco items and their smoke contain nicotine. When warm it emits a fishy odor. Workers processing and extracting tobacco have a higher chance of exposure. Formerly it was used as a fumigant and insecticide in the United States, but has been discontinued from use now. The nervous system and cardiac functions are affected by nicotine and even a small amount of exposure may prove fatal.

Nicotine Poisoning is related to the following process: Poison.

Presentation

Toxicity is usually presented in two stages and symptoms presented mainly depend on type of subjection. 

  • Early - stimulation/excitation within 15 minutes to 1 hour and may last up to 1 to 2 hours. The most vital symptom associated with nicotine toxicity is vomiting.
  • Late - inhibition/depression within  30 minutes to 4 hours. Some cases exhibit only late phase symptoms. Symptoms last up to 18 to 24 hours after exposure in serious cases. Severe toxicity may lead to death in 1 hour after exposure.

Major symptoms to look out include:

  • Irritation and redness (erythema) of eye, intense pain and inflammation of conjunctiva in case of direct eye contact with pure nicotine and in severe cases, this may often lead to cornea opacification.
  • Whole-body (systemic) toxicity in case of dermal and mucosal exposure
  • Allergic reactions
  • Green tobacco disease symptoms in occupational handlers

Skin
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  • Ears
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  • Eyes
    Blurred Vision
    • , diarrhea , cold sweat, blurred vision , hearing difficulties, mental confusion, weakness and fainting.[symptoma.com]
    • Overdose symptoms include: bad headaches, dizziness, upset stomach, drooling, vomiting, diarrhea , cold sweat, blurred vision, hearing difficulties, mental confusion, weakness and fainting.[rxlist.com]
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  • psychiatrical
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  • cardiovascular
    Tachycardia
    • Hypertension , tachycardia and hyperpnea are the cardiopulmonary symptoms presented.[symptoma.com]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • However, the half life with large overdoses is not well studied and it may take up to 72 hours for symptoms to fully clear. [4] System Early Effects ( Delayed Effects ( 1hr) Cardiovascular Tachycardia, hypotension Bradyarrythmia, hypotension Respiratory[canadiem.org]
    • Tremors Weakness Stumbling and/or incoordination Depression Hyperactivity Lethargy (in high doses) Fast breathing or difficulty breathing Drooling Dilated pupils Vomiting Diarrhea Possible seizures Collapse Either bradycardia (slow heart rate), tachycardia[petplace.com]
    Hypertension
    • Causes Hypertension Early cardiopulmonary symptoms consist of hypertension , tachycardia and hyperpnea.[symptoma.com]
    • Early cardiopulmonary symptoms consist of hypertension, tachycardia and hyperpnea.[calpoison.org]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • Accelerated Hypertension Nicotine therapy constitutes a risk factor for development of malignant hypertension in patients with accelerated hypertension; therefore, NICOTROL (nicotine inhalation system) Inhaler therapy should be used with caution in these[rxlist.com]
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  • musculoskeletal
    Muscle Twitch
    • [symptoma.com] more... musculoskeletal Muscle Twitch From this stage, patients can rapidly progress to more serious symptoms including muscle twitching , weakness, seizures, hypotension, bradycardia, respiratory depression, coma and paralysis.[symptoma.com]
    • From this stage, patients can rapidly progress to more serious symptoms including muscle twitching, weakness, seizures, hypotension, bradycardia, respiratory depression, coma and paralysis.[calpoison.org]
    • twitching Palpitations (fast and pounding heartbeat often followed by slow heart rate) Vomiting Weakness Seek immediate medical help.[nlm.nih.gov]
    • Muscle twitches – This can be caused by the restriction of blood vessels, but there is also some evidence to suggest that the nicotine itself can cause this reaction.[nobullying.com]
    Muscle Cramp
    • . - B Simon, P Solomon - RCP Acute nicotine poisoning associated with a traditional remedy for eczema - P Davies, S Levy, A Pahari, D Martinez - Archives of disease in , 2001 - adc.bmj.com Aetiology of skeletal muscle 'cramps' during exercise: a novel[symptoma.com]
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  • gastrointestinal
    Vomiting
    • If your dog is not vomiting, you can induce vomiting, by administering 1 glass of water that contains 1 tbsp of hydroxide peroxide.[vetinfo.com]
    • [symptoma.com] more... gastrointestinal Vomiting If your dog is not vomiting , you can induce vomiting , by administering 1 glass of water that contains 1 tbsp of hydroxide peroxide.[symptoma.com]
    • Pets ingesting small amounts of nicotine often vomit spontaneously and may self-decontaminate.[petpoisonhelpline.com]
    • It is likely that your vet will want to induce vomiting if the animal hasn't already vomited, administer activated charcoal, and start supportive therapy in the form of IV fluids and medications to control seizures and other nervous system effects.[vetmedicine.about.com]
    • […] by the fact that relatively low doses of nicotine cause nausea and vomiting, which stops users from further intake." [22] Four adults died in the US and Europe, after intentionally ingesting liquid. [23] Two children, one in the US in 2014 and another[en.wikipedia.org]
    Nausea
    • […] of tobacco or other products containing nicotine [tobaccoinaustralia.org.au] Nausea Fifteen minutes after ingestion symptoms were nausea and shivering.[symptoma.com]
    • Fifteen minutes after ingestion symptoms were nausea and shivering.[blog.rursus.de]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • Eat something in general — if you can keep food down, eating something light and easy to digest (like toast, rice, bananas, or an apple) may help ease nausea as well.[hubpages.com]
    • However dizziness, nausea and vomiting may occur in response to tobacco use before tolerance is established. 1 These symptoms also accompany cases of acute nicotine poisoning, which may occur through ingestion of tobacco or other products containing nicotine[tobaccoinaustralia.org.au]
    Diarrhea
    • [kpbs.org] Diarrhea But even a mild case can cause diarrhea , vomiting, ataxia, seizures, and heart attacks.[symptoma.com]
    • Symptoms of Nicotine Poisoning Nicotine poisoning will be signaled by a number of symptoms that may include: Chronic vomiting, as the dog tries to eliminate the harmful substances Diarrhea Coughing Shaking Excessive drooling Small pupils Dehydration Agitation[vetinfo.com]
    • But even a mild case can cause diarrhea, vomiting, ataxia, seizures, and heart attacks.[drvapeit.com]
    • Diarrhea, seizures, a physical collapse and an abnormal heart rate are also common.[second-opinion-doc.com]
    • “Symptoms of mild nicotine poisoning include nausea, vomiting and diarrhea,” said Ashley N.[nortongethealthy.com]
    Abdominal Pain
    • The only symptoms were nausea, abdominal pain, shivering and voluminous vomiting.[blog.rursus.de]
    • Pain The only symptoms were nausea, abdominal pain , shivering and voluminous vomiting.[symptoma.com]
    • They reported common symptoms of Green Tobacco Sickness (GTS), or nicotine poisoning, including severe headaches, abdominal pain, muscle weakness, coughing and breathlessness.[fctc.org]
    • A smaller amount of nicotine absorbed over time will cause such obvious symptoms -- abdominal pain, nausea, and sweating -- that the victim is likely to seek treatment.[cbsnews.com]
    • One case study documents a person who ingested 1,500 milligrams of liquid nicotine and survived, suffering no worse than " abdominal pain and voluminous vomiting ."[kpbs.org]
    Abdominal Cramps
    • Symptoms of nicotine poisoning include: Abdominal cramps Agitation , restlessness, excitement, or confusion Burning sensation in mouth, drooling (increased saliva) Fainting or even coma Convulsions Depression Breathing that may be difficult, rapid, or[nlm.nih.gov]
    • A few of the most common signs are: Anxiety attacks Insomnia Agitation Depression Ringing in the ears Muscle spasms and twitching Coma Convulsions Rapid heart rate Skyrocketing blood pressure Chest pain Dizziness Vomiting Abdominal cramps Panic attacks[myfinalsmoke.com]
    • [kpbs.org] Abdominal Cramps Symptoms of nicotine poisoning include: Abdominal cramps Agitation , restlessness, excitement, or confusion Burning sensation in mouth, drooling (increased saliva) Fainting or even coma Convulsions Depression Breathing that[symptoma.com]
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  • respiratoric
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  • neurologic
    Seizure
    • Benzodiazepines are usually effective for treating seizures .[symptoma.com]
    • Benzodiazepines are usually effective for treating seizures.[calpoison.org]
    • Diarrhea, seizures, a physical collapse and an abnormal heart rate are also common.[second-opinion-doc.com]
    • The most common signs of tobacco or nicotine toxicity can seem like a drug overdose and may include vomiting, diarrhea, trembling, drooling, constricted pupils, excitement, odd behavior, and seizures.[vetmedicine.about.com]
    • A nicotine overdose may cause seizures or death.[nlm.nih.gov]
    Dizziness
    • [kpbs.org] Dizziness Early signs of accidental nicotine poisoning include burning in the mouth and throat, nausea and/or vomiting, confusion and dizziness , and weakness and excess spittle. 30) The authors of a case report of nicotine poisoning in an[symptoma.com]
    • Early signs of accidental nicotine poisoning include burning in the mouth and throat, nausea and/or vomiting, confusion and dizziness, and weakness and excess spittle. 30) The authors of a case report of nicotine poisoning in an infant call on doctors[thefreedictionary.com]
    • Green tobacco sickness secondary to prolonged dermal exposure to wet tobacco (eg. in tobacco workers) is characterized by nausea, vomiting, headaches, dizziness and diaphoresis.[calpoison.org]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • A nicotine overdose usually makes a person sweaty, clammy, dizzy and nauseous.[news.psu.edu]
    Headache
    • [tobaccoatlas.org] Headache – Restricted blood flow cuts off oxygen to the brain, which can cause headaches .[symptoma.com]
    • At the end, most of this dies and then you remain with a headache," one child said.[fctc.org]
    • Headache – Restricted blood flow cuts off oxygen to the brain, which can cause headaches.[nobullying.com]
    • Symptoms of nicotine withdrawal include intense craving, anxiety, depression, headache, increased appetite, and difficulty concentrating.[tobaccoatlas.org]
    • The first symptoms are usually as a result of the stimulating nature of nicotine and these symptoms include things like vomiting, hypertension, headaches, excessive salivation and even seizures.[quitsmokingcommunity.org]
    Confusion
    • [quitsmokingcommunity.org] Confusion Panic attacks – This is linked to the confusion and extreme anxiety.[symptoma.com]
    • Panic attacks – This is linked to the confusion and extreme anxiety.[nobullying.com]
    • Early signs of accidental nicotine poisoning include burning in the mouth and throat, nausea and/or vomiting, confusion and dizziness, and weakness and excess spittle. 30) The authors of a case report of nicotine poisoning in an infant call on doctors[thefreedictionary.com]
    • Other symptoms may include: Agitation or confusion Breathing difficulties Loss of consciousness or coma Convulsions Heartbeat irregularities Rapid changes in blood pressure In severe cases, nicotine poisoning can also result in death .[cochranfirm.com]
    • Symptoms of Heat Exhaustion Headache, dizziness, or fainting Weakness and wet skin Irritability or confusion Thirst, nausea, or vomiting Symptoms of Heat Stroke May be confused, unable to think clearly, pass out, collapse, or have seizures (fits) Increased[osha.gov]
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  • Entire body system
    Pallor
    • Entire body system Pallor The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations[symptoma.com]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • Overdosage & Contraindications OVERDOSE Signs and Symptoms of Nicotine Toxicity Signs and symptoms of an overdose of the NICOTROL (nicotine inhalation system) Inhaler would be expected to be the same as those of acute nicotine poisoning including: pallor[rxlist.com]
    • A self-limiting illness known as "green-tobacco sickness" has been described in young man handling uncured tobacco leaves in the field; it consists of pallor, vomiting and prostration and is probably due to the percutaneous absorption of nicotine from[inchem.org]
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  • Workup

    The best way to diagnosis nicotine toxicity is by correlating clinical findings with history of exposure. Urine toxicology test allows physicians to confirm presence of  nicotine and its metabolite (cotinine), but it may not help in diagnosis owning to its qualitative nature and universality of smoking. Serum levels tests are equally difficult to interpret and is also time consuming rendering it useless in case of acute poisoning management. Patients sufferering from respiratory distress in severe cases should be managed by intubation and mechanical ventilation.

    Recommendations for management of nicotine poisoning given by Amy Hanoian-Fontana of Connecticut Poison Control Center include:

    • Patients exhibiting typical symptoms of nicotine toxicity must seek emergency medical treatment.
    • In suspected cases of toxicity with no symptoms, patients after informing the poison control center should stay home and center will follow up every few hours to monitor the progress.
    • Washing of skin with copious amount of lukewarm water for 20 minutes in case of accidental spillage of liquid nicotine. 

    Treatment

    Treatment options available for nicotine poisoning is directed towards easing the clinical symptoms mainly owning to the lack of specific antidote treatrment for nicotine toxicity. Patients exhibiting toxicity symptoms after nicotine ingestion should be given a gastric lavage with activated charcoal. Nicotine is mainly metabolized in liver by enterohepatic recirculation. Therefore, treatment using activated charcoal (up to 4 times, at 1 to 2 hours interval) will help to effectively detoxify nicotine through nicotine charcoal binding. Charcoal treatment should not be performed in patients suffering from vomiting, seizures or coma. Mecamylamine, a specific nicotine antagonist in the form of tablet can be used for managing nicotine poisoning when the patient is not convulsive, hypotensive or vomiting.

    Benzodiazepines are the class of drugs used in managing seizures. Hypotension is managed initially with fluids followed by administration of vasopressors in refractory cases. Patients suffering from respiratory distress is stabilized by intubation and mechanical ventilation. Muscarnic symptoms including bradycardia is treated with atropine. Intravenous administration of atropine is recommended for treating adult patient (2 to 3 mg) and pediatric patients (0.02mg/kg). The procedure must be repeated if necessary.

    Nicotine toxicity through skin contact is treated by rigorous cleansing with soap and water. The standard observation time set for oral and skin contact toxicity is 4-6 hours from exposures. Longer periods of observation is required in case of ingestion of intact nicotine patches or tobacco plant materials.

    Prognosis

    Clinical symptoms on acute exposure present within 15-90 minutes after exposure and mainly include nausea, salivation, vomiting, dizziness, confusion and diaphoresis. Hypertension, tachycardia and hyperpnea are the cardiopulmonary symptoms presented. These manifestations are considered as cases of minor toxicity or temporary early symptoms of  severe poisoning. In such cases, condition can quickly deteriorate to more serious symptoms like muscle twitching, weakness, seizures, bradycardia, hypotension, hypoventilation, coma and paralysis.

    Recommended exposure limit (REL) and threshold limit value (TLV) for nicotine is 500 µg per m3 as per recommendations of the National Institute for Occupational Safety and Health (NIOSH) and the American Conference of Governmental Industrial Hygienists’ (ACGIH) respectively. Time-weighted average subjection to 2.3 µg per m3 of nicotine for 8 hours  was shown to result in three lung cancer induced deaths per 10,000 people exposed to nicotine over a working lifetime by a model used to determine the health-based standard for environmental tobacco smoke [15].

    Clinical manifestations of nicotine toxicity last for about 1-2 hours in case of minor poisoning and to about 24 hours in severe cases. Paralysis of respiratory muscles and circulatory collapse results in demise within 1 hour after acute exposure. Skin contact to wet tobacco plant lead to green tobacco sickness with symptoms like nausea, vomiting, headaches, giddiness and diaphoresis within 3 to 17 hours from exposure that may last up to three days.

    Complications

    Coma
    • Complications Coma Severe nicotine poisoning can lead to convulsions, irregular heartbeat, coma and even cardiac arrest.[symptoma.com]
    • Severe nicotine poisoning can lead to convulsions, irregular heartbeat, coma and even cardiac arrest.[thefreedictionary.com]
    • From this stage, patients can rapidly progress to more serious symptoms including muscle twitching, weakness, seizures, hypotension, bradycardia, respiratory depression, coma and paralysis.[calpoison.org]
    • Other symptoms may include: Agitation or confusion Breathing difficulties Loss of consciousness or coma Convulsions Heartbeat irregularities Rapid changes in blood pressure In severe cases, nicotine poisoning can also result in death .[cochranfirm.com]
    • Nicotine poisoning will be signaled by a number of symptoms that may include: Chronic vomiting, as the dog tries to eliminate the harmful substances Diarrhea Coughing Shaking Excessive drooling Small pupils Dehydration Agitation and irritability Seizures Coma[vetinfo.com]
    Hypertension
    • Causes Hypertension Early cardiopulmonary symptoms consist of hypertension , tachycardia and hyperpnea.[symptoma.com]
    • Early cardiopulmonary symptoms consist of hypertension, tachycardia and hyperpnea.[calpoison.org]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • Accelerated Hypertension Nicotine therapy constitutes a risk factor for development of malignant hypertension in patients with accelerated hypertension; therefore, NICOTROL (nicotine inhalation system) Inhaler therapy should be used with caution in these[rxlist.com]
    Asthma
    • It contributes to serious health issues in children and adults, including asthma, nasal polyps, lung cancer and heart disease.[nortongethealthy.com]
    • [symptoma.com] Asthma Second-hand smoke inhaled by children has been linked to an increase in childhood asthma .[symptoma.com]
    • It causes lung infections, an increased risk of allergies and asthma , COPD , and numerous other health issues.[quitsmokingcommunity.org]
    • Bronchospastic Disease NICOTROL (nicotine inhalation system) Inhaler has not been specifically studied in asthma or chronic pulmonary disease.[rxlist.com]

    Etiology

    The use of nicotine is illegal for minors owning to its addictive nature and the potential for overdose. Taking large quantities of nicotine through cigarettes, gum, e-liquid and patches may result in an overdose. Recommendations to prevent overdosing and fatality include quitting e-liquid drinking and avoiding the use of patches, gum, combinations of recreational products containing nicotine while smoking.

    Nicotine is capable of contaminating water and food. It contaminates the indoor and outdoor air as fine particles or as spray (aerosol). In case of outdoor contamination it may result in contamination of agricultural products also. The route of exposure to nicotine include absorption through inhalation, ingestion, mucous membranes and skin. Nicotine induced toxicity through skin contact have been reported in nicotine containing pesticides handlers [5] and tobacco field workers [6].

    Based on the route of nicotine administration and the particular type used, the LD50 (concentration lethal to 50 % of test subjects) varies in experimental animals. The variation in nicotine sensitivity observed in rodents is assumed to be genetically acquired [7].

    Causes

    Hypertension
    • Causes Hypertension Early cardiopulmonary symptoms consist of hypertension , tachycardia and hyperpnea.[symptoma.com]
    • Early cardiopulmonary symptoms consist of hypertension, tachycardia and hyperpnea.[calpoison.org]
    • The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor , sweating, hypertension , tachycardia , ataxia , tremor, headache, dizziness, muscle fasciculations , and seizures[en.wikipedia.org]
    • Accelerated Hypertension Nicotine therapy constitutes a risk factor for development of malignant hypertension in patients with accelerated hypertension; therefore, NICOTROL (nicotine inhalation system) Inhaler therapy should be used with caution in these[rxlist.com]
    Toxic Plant
    • Other toxic plants include poinsettias, aloe vera, branching ivy, fern, carnations, daffodils and eucalyptus.[pets.thenest.com]

    Epidemiology

    Oral exposure of nicotine leads to acute toxic effects [8]. The major symptoms of toxicity upon subjection (2 mg to 5 mg) include nausea. In case of adults, ingestion of large quantities (40 mg to 60 mg) of nicotine may lead to death. A sizable number of human poisoning and deaths have been reported from exposure to nicotine-containing pesticides [6].

    Dermal exposure from accidental spilling, purposeful application of nicotine-containing insecticides on skin, contact with tobacco leaves on clothes will all result in poisoning [9]. Children may suffer from acute intoxication by ingesting tobacco containing supplies. One particular case was reported where four children developed salivation, vomiting, diarrhoea, tachycardia, tachypnoea and hypertension within 30 minutes of ingestion of two cigarettes each. Symptoms of depressed respiration and cardiac arrhythmia followed within 40 minutes  and convulsions were observed within 60 minutes [10]. Prolonged exposure to nicotine in smaller quantities (e.g. smoking) will result in chronic toxicity [11]. Increased chance of low birth weight and spontaneous abortion are reported in expectant mother smokers [6]. Short term skin contact with pharmaceutical and insecticidal nicotine products leads to serious toxicity. Green tobacco sickness as the name implies is caused by occupational tobacco plant handling. Second hand smoking resulted in 49,000 of the total 440,000 deaths in America related by chronic cigarette smoking [12].

    California Poison Control System received reports of 557 nicotine exposure in 2004. Majority of the victims were children under five years (85%). Recreational tobacco products (e.g.cigarettes, chewing tobacco), pharmaceutical preparations (e.g.patches, gum, lozenges) and nicotine-containing plants resulted in 481 (86%), 72(13%) and 4 cases (1%) respectively. Fortunately patients involved did not suffer any serious toxicity despite the former reports of lethal poisonings  and deaths associated with exposure and ingestion of raw plants, nicotine insecticides, pharmaceutical preparations and commercially prepared recreational products [6] [12].

    Sex distribution
    Age distribution

    Pathophysiology

    The quantity of nicotine required to produce lethal effects in human is 60 mg or less corresponding to an oral LD50 of 0.8 mg per kg [13].  Nicotine poisoning does not produce any specific histological changes however evidence of caustic effect of nicotine has been observed in the gastrointestinal tract (GIT) after ingestion. Skin along with mucosal membranes of lungs, mouth, GIT and rectum absorb nicotine upon exposure. The elimination half-life of nicotine is 2 hours and has a distribution volume of approximately 1 L/kg. Immediately dangerous to life or health concentration (IDLH) is not determined for nicotine due to lack of inhalation toxicity data. The updated IDLH value for nicotine is given as  5 mg per m3 of skin surface. The value is derived from the acute oral toxicity figures in humans and animals [14].

    Nicotine acts by  stimulating the nicotinic acetylcholine receptors of  -

    1. Autonomic nervous system - Adrenal medulla exhibits a "biphasic action" upon nicotine toxicity. Nicotine poisoning at lower doses result in  catecholamine release and  at higher doses result in inhibition in catecholamine release
    2. Central nervous system -  Low dose exposure to nicotine result in mild insentience and respiratory stimulation and  higher doses may lead to seizures and respiratory depression
    3. Neuromuscular junction - Fasciculations due to neuromuscular stimulation is ensued by neuromuscular blockade manifested as frailty and respiratory arrest

    Time to attain peak serum levels differs widely depending upon the type and quantity of nicotine consumed. In case of chewing nicotine gum, nicotine serum concentration peaks around 30 minutes. Mean steady-state levels of 11.8ng /ml of serum concentration is  observed after consumption of 2 mg of gum. 5 to 10 minutes is the time required to attain maximum nicotine levels in case of cigarette smoking.

    Prevention

    First responders entering a nicotine contaminated area should wear a NIOSH-certified chemical, biological, radiological, nuclear (CBRN) self contained breathing apparatus (SCBA) and a level A protective suit. Level A protection must be exercised until the contaminant is identified and its concentration is determined. Training and experience will help responders to use protective clothing and equipment effectively under such circumstances. In an effort to prevent the accidental ingestion of nicotine, Child Nicotine Poisoning Prevention Act (2015) has instructed Consumer Product Safety Commission (CPSC) to implement a mandatory redesigning of liquid nicotine containers to prevent children under age five from opening and consuming its contents. 

    Summary

    Nicotine is the major alkaloid (95 % of the total content) present in commercial tobacco [2]. It is a central nervous system stimulant and is highly addictive. Over 4.9 million tobacco-associated deaths are reported annually. It is the major cause of death in present day and is more dangerous and fatal than any other consumer products [3]. 95% of cigarette toxicity reported is either symptom less (70%) or mild (25%). The recent reports of severe nicotine toxicity are from workers who are accidentally exposed to the animal control agents. Appropriate respiratory and cardiovascular aid will help patients suffering from delayed effects of exposure to recover without any lasting effects (sequelae). 

    The modern versions of cigarettes like battery powered devices (electronic cigarettes, or e-cigarettes) provide nicotine doses as aerosol. E-cigarette cartridges generally contain nicotine, aerosol producing component (e.g. glycerol or propylene glycol) and flavorings (e.g. fruit, chocolate or mint). Presence of potentially dangerous components like irritants, genotoxins, and animal carcinogen has also been reported. Food and Drug Administration poses no regulation for non therapeutic uses of such e-cigarettes and is thus legally available to minors in many states. Recent reports suggest an increase in the usage of e-cigarettes among the present and former smokers in the United States. The popularity of e-cigarettes among young adults is yet to be ascertained [4]. Nicotine is a known teratogen (causative agent of birth defects) but their potential for carcinogenesis, developmental and reproductive toxicity is yet to be studied.

    Patient Information

    Presence of nicotine in the body results in symptoms like nausea, vomiting or seizures.

    Current statistics on source of nicotine poisoning is as follows:

    • Recreational tobacco supplies (cigarettes, chewing tobacco) -  481 cases (86%)
    • Medical preparations (patches, gum, lozenges) - 72 cases (13%)
    • Tobacco plants -  4 cases (1%)

    Even though none of the above cases resulted in serious conditions and death, it is worth while to know that serious and lethal nicotine poisoning do have occurred previously from ingestion of raw plant, insecticides containing insecticides, medicinal preparations and recreational tobacco supplies. Inhalation, absorption (through skin and mucous membranes) and ingestion of liquid nicotine from e-cigarettes will result in nicotine poisoning.

    Nicotine poisoning symptoms go through (but not always) two phases:

    1. early phase - stimulation/excitation within 15 minutes to 1 hour of exposure
    2. late phase - inhibition/depression within 30 minutes to 4 hour. Many victims may display late phase only 

    Symptoms of poisoning depend on the type and route of exposure. Vomiting is the most important symptom to look out for in case of nicotine poisoning. The symptoms last for approximately 1 to 2 hours after light exposures, but may continue up to 18 to 24 hours in case of severe exposure. Severe cases  may result in death within 1 hour of poisoning. Atropine is the antidote used to treat nicotine toxicity (should only be used when there is no vomiting, convulsions and hypotension). In case of nicotine exposure, seek emergency medical care or inform poison control center (1-800-222-1222).

    Self-assessment

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    References

    1. Schevelbein H. Nicotine, resorption and fate. Pharm Ther. 1982;18:233–248.
    2. Jacob P 3rd, Yu L, Liang G, Shulgin AT, Benowitz NL. Gas chromatographic-mass spectrometric method for determination of anabasine, anatabine and other tobacco alkaloids in urine of smokers and smokeless tobacco users. J Chromatogr. 1993;619:49-61.
    3. WHO. An international treaty for tobacco control. World Health Organization,Geneva. http://www.who.int/features/2003/08/en/
    4. Cobb NK, Byron MJ, Abrams DB, Shields PG. Novel nicotine delivery systems and public health: the rise of the "e-cigarette". Am J Public Health. 2010;100(12):2340-2342.
    5. Yildiz D. Nicotine, its metabolism and an overview of its biological effects. Toxicon. 2004;43:619-632.
    6. Health Council of the Netherlands: Committee on Updating of Occupational Exposure Limits. Nicotine; Health-based Reassessment of Administrative Occupational Exposure Limits. The Hague: Health Council of the Netherlands, 2005.
    7. Marks MH, Burch JB, Collins AC. Genetics of nicotine response in four inbred strains of mice. J Pharmacol Exp Ther. 1983;226:291-302.
    8. ICSC. Nicotine Material Safety Data Sheet. Nicotine ICSC: 0519. International Chemical Safety Cards. https://www.erowid.org/chemicals/nicotine/nicotine_data_sheet1.shtml Published 1993. Accessed September 05, 2015.
    9. Benowitz NL, Lake T, Keller KH, Lee BL. Prolonged absorption with development of tolerance to toxic effects following cutaneous exposure to nicotine. Clin Pharmacol Ther. 1987;42:119-120.
    10. Malizia E, Andreucci G, Alfani F, Smeriglio M, Nicholai P. Acute intoxication with nicotine alkaloids and cannabinoids in children from ingestion of cigarettes. Hum Toxicol. 1983;2:315-316.
    11. US-EPA. Chemical profile: Nicotine. US Environmental Protection Agency; 1987.
    12. Centers for Disease Control and Prevention. Cigarette Smoking in the United States. http://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html#two. Accessed: ‎February ‎06, ‎2014.
    13. Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology. 2014;88(1):5-7.
    14. CDC, NIOSH:Documentation for Immediately Dangerous to Life or Health Concentrations (IDLH). Nicotine. National Institute for Occupational Safety and Health. http://www.cdc.gov/niosh/idlh/intridl4.html. Published 1994, Accessed September 2,2015.
    15. Trout D, Decker J, Mueller C, Bernert JT, Pirkle J. Exposure of casino employees to environmental tobacco smoke. J Occup Environ Med. 1998;40:270-276.

    • Acute nicotine poisoning associated with a traditional remedy for eczema - P Davies, S Levy, A Pahari, D Martinez - Archives of disease in , 2001 - adc.bmj.com
    • Acute nicotine poisoning associated with a traditional remedy for eczema - P Davies, S Levy, A Pahari, D Martinez - Archives of disease in , 2001 - adc.bmj.com
    • An unusual case of nicotine poisoning - H GARCIA-ESTRADA - Clinical , 1977 - informahealthcare.com
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