| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical presentation |
- Toxicity develops rapidly (within minutes to 1 hour) after ingestion or dermal exposure to concentrated nicotine products (eg, e-cigarette cartridges or industrial, agricultural, or insecticide exposures) or after ingestion of >0.1 mg/kg of tobacco or nicotine products.
- Toxicity may be delayed after ingestion or cutaneous application of a transdermal nicotine patch or dermal exposure to wet tobacco plants (green tobacco sickness).
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| Acute toxicity |
Toxicity is caused by nicotine binding to nicotinic acetylcholinesterase receptors in the brain, the spinal cord (postganglionic sympathetic and parasympathetic neurons), and at the neuromuscular junction. Patients may rapidly progress from mild to moderate or severe toxicity: - Mild:
- Nausea and vomiting
- Salivation
- Drowsiness
- Hyperactivity (for infants, fussy but consolable)
- Tachycardia
- Pallor
- Diaphoresis
- Dizziness
- Moderate:
- Hypertension
- Bronchorrhea, wheezing, repeated vomiting, and/or diarrhea
- Tachypnea secondary to bronchorrhea
- Tremors
- Muscle fasciculations
- Ataxia
- Confusion, agitation, lethargy, irritability (for infants, inconsolable crying)
- Severe:
- Bradyarrhythmias, cardiac arrest
- Hypotension
- Respiratory failure secondary to muscle paralysis
- Seizures
- Coma
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| Diagnostic evaluation |
| Nicotine poisoning is a clinical diagnosis based upon a history of nicotine or tobacco exposure and clinical features; definitive laboratory testing is not available in a timely fashion but may be indicated to confirm exposure (obtain blood and urine samples for cotinine and other nicotine metabolites). |
Obtain ancillary studies based upon degree of toxicity: - Asymptomatic or mild toxicity (monitor closely for worsening toxicity):
- Exploratory or unintentional exposure: No studies necessary
- Intentional exposure for self-harm: Acetaminophen and salicylate plasma levels
- Moderate to severe:
- ECG
- Rapid plasma glucose
- Arterial or venous blood gas
- Electrolytes
- Serial measures of creatine kinase and urinalysis for patients with muscle fasciculations, seizures, and/or paralysis to assess presence of rhabdomyolysis
- Plasma and red blood cell cholinesterase (to differentiate from organophosphate or carbamate poisoning)
- In patients with seizures and all pediatric patients, urine screening for drugs of abuse
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| Management |
| There is no antidote for nicotine poisoning; treatment is supportive. |
PPE: - No special PPE is needed for nicotine ingestion.
- For dermal exposures with concentrated nicotine products or industrial, agricultural, or insecticide exposures, providers should wear a waterproof gown, gloves, and eye protection.
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Decontamination: Perform decontamination in conjunction with stabilization of airway, breathing, circulation, and other emergency therapies. - Dermal exposure (eg, spilled e-cigarette liquid, nicotinic pesticides, or damp plant material [green tobacco sickness]):
- Wipe off any liquid on the skin.
- Remove all clothing and transdermal nicotine patches.
- Cover any open wounds and then irrigate skin with lukewarm water with mild soap, rinse with lukewarm water, pat dry, and cover the patient with warmed linens/blankets to prevent hypothermia (use beside warmer in infants and young children).
- Large ingestion of concentrated liquid nicotine: After assuring the airway is protected as needed, nasogastric aspiration of stomach contents may be attempted although efficacy is uncertain. Within 1 hour of a potentially toxic ingestion of nicotine or a tobacco product or within 3 hours of ingestion of a transdermal nicotine patch, administer activated charcoal without sorbitol 1 g/kg (maximum single dose 50 g).
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| Moderate to severe poisoning |
Cholinergic toxicity: - Deliver 100% oxygen via facemask; timely intubation may be required for coma, seizures, skeletal muscle weakness/paralysis, or bronchorrhea not responsive to atropine; avoid succinylcholine.
- Atropine 0.01 to 0.02 mg/kg IV/IM up to 2 mg maximum single dose; repeat every 3 to 5 minutes, targeting drying of bronchial secretions and clearing of wheezing; tachycardia is not a contraindication to atropine.
- Inhaled ipratropium bromide 0.5 mg by nebulizer for wheezing.
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Shock or cardiac arrhythmias: - Treat hypotension with rapid infusion of isotonic saline or balanced crystalloid solutions (eg, lactated Ringer) according to the degree of shock and presence of pre-existing conditions (eg, heart failure); provide continuous infusion of norepinephrine or epinephrine for fluid-refractory shock.
- Sinus bradycardia with hypotension or bradyarrhythmias: Atropine as above; patients unresponsive to atropine should receive treatment according to ACLS and PALS algorithms for bradycardia.
- Tachyarrhythmias (SVT or VT): Treat according to ACLS and PALS algorithms.
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Seizures: - Benzodiazepines (eg, lorazepam 0.1 mg/kg up to 4 mg per dose, repeat every 5 minutes as needed); if additional anticonvulsant is needed, phenobarbital is preferred; avoid fosphenytoin or phenytoin. For refractory convulsive status epilepticus, continuous midazolam infusion is preferred.
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Paralysis: - Pralidoxime is ineffective for nicotine poisoning. If there is no clear history of nicotine exposure or organophosphate exposure is also suspected, a trial loading dose of 30 mg/kg (maximum single dose 2 g) given IV over 15 to 30 minutes is reasonable. Refer to UpToDate content on organophosphate poisoning.
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Rhabdomyolysis: - Continuous infusion of IV normal saline to maintain urine output of 200 to 300 mL/hour (adults) and urinary alkalinization.
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| Asymptomatic exposure or mild poisoning |
- Closely monitor for progression to moderate or severe poisoning.
- Observe patients with transdermal patch ingestion for 24 hours because toxicity may be delayed.
- Patients who are asymptomatic after 6 hours of observation may be discharged home or, for patients who intended self-harm, cleared for mental health evaluation.
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