Nicotine poisoning

Nicotine poisoning
Classification and external resources
Nicotine
ICD-10	F17.0, T65.2
DiseasesDB	30389
MedlinePlus	002510

Nicotine poisoning describes the symptoms of the toxic effects of consuming nicotine, which can potentially be deadly.^[1] Historically, most cases of nicotine poisoning have been the result of use of nicotine as an insecticide.^[2][3] More recent cases of poisoning typically appear to be in the form of Green Tobacco Sickness or due to accidental ingestion of tobacco or tobacco products or ingestion of nicotine containing plants.^[4][5][6]

The probable lethal dose of nicotine has been reported as between 40 and 60 milligrams (the total amount in about 2 cigarettes if all of the nicotine was absorbed) in adults and about 1 mg/kg in children (less than 1 cigarette) .^[7][8][9] Children may become ill following ingestion of one cigarette,^[10] ingestion of more than this may cause a child to become severely ill.^[11][5] In some cases children have become poisoned by topical medicinal creams which contain nicotine.^[12]

People who harvest or cultivate tobacco may experience Green Tobacco Sickness (GTS), a type of nicotine poisoning caused by dermal exposure to wet tobacco leaves. This occurs most commonly in young, inexperienced tobacco harvesters who do not use tobacco.^[4][13]

Toxicology

The LD₅₀ of nicotine is 50 mg/kg for rats and 3 mg/kg for mice. 0.5-1.0 mg/kg can be a lethal dosage for adult humans, and 0.1 mg/kg for children.^[9][14] Nicotine therefore has a high toxicity in comparison to many other alkaloids such as cocaine, which in mice has an LD₅₀ of 95.1 mg/kg.

A person can overdose on nicotine through a combination of nicotine patches, nicotine gum, nicotine inhaler cartridges and/or tobacco smoking at the same time.^[15][16] Ingestion of nicotine pharmaceuticals, tobacco products, or nicotine containing plants may also lead to poisoning.^[4][5][6] Smoking excessive amounts of tobacco has also led to poisoning; a case was reported where two brothers smoked 17 and 18 pipes of tobacco in succession and were both fatally poisoned.^[2] Spilling an extremely high concentration of nicotine onto the skin can result in intoxication or even death since nicotine readily passes into the bloodstream following skin contact.^[17][18]

Signs and symptoms

Nicotine poisoning tends to produce symptoms that follow a biphasic pattern. 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.^[4] After the initial stimulatory phase, a later period of depressor effects can occur and may include symptoms of hypotension and bradycardia, central nervous system depression, coma, muscular weakness and/or paralysis, with difficulty breathing or respiratory failure.^{[4][1][19][20]}

Pathophysiology

The symptoms of nicotine poisoning are caused by excessive stimulation of nicotinic cholinergic neurons. Nicotine is an agonist at nicotinic acetylcholine receptor which are present in the central and autonomic nervous systems, and the neuromuscular junction. At low doses nicotine causes stimulatory effects on these receptors, however, higher doses or more sustained exposures can cause inhibitory effects leading to neuromuscular blockade.^[4][21]

It is sometimes reported that people poisoned by organophosphate insecticides experience the same symptoms as nicotine poisoning. Organophosphates inhibit an enzyme called acetylcholinesterase, causing a build up of acetylcholine, excessive stimulation of all types of cholinergic neurons, and a wide range of symptoms. Nicotine is specific for nicotinic cholinergic receptors only and has some, but not all of the symptoms of organophosphate poisoning.

Diagnosis

Increased nicotine or cotinine (the nicotine metabolite) is detected in urine or blood, or serum nicotine concentrations increase.

Treatment

The initial treatment of nicotine poisoning may include the administration of activated charcoal to try and reduce gastrointestinal absorption. Treatment is mainly supportive and further care can include control of seizures with the administration of a benzodiazepine, intravenous fluids for hypotension, and administration of atropine for bradycardia. Respiratory failure may necessitate respiratory support with rapid sequence induction and mechanical ventilation. Hemodialysis, hemoperfusion or other extracorporeal techniques do not remove nicotine from the blood and are therefore not useful in enhancing elimination.^[4] Acidifying the urine could theoretically enhance nicotine excretion,^[22] although this is not recommended as it may cause complications of metabolic acidosis.^[4]

Prognosis

The prognosis is typically good when medical care is provided and patients adequately treated are unlikely to have any long-term sequelae. However, severely affected patients with prolonged seizures or respiratory failure may have ongoing impairments secondary to the hypoxia.^[4][23] It has been stated that if a patient survives nicotine poisoning during the first 4 hours, they usually recover completely.^[20]

References

External links

• How Stuff Works:Nicotine
• Nicotine Poisoning In Pets

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