Symptomatic bradycardia due to nicotine intoxication

Abstract

Nicotine is a dangerous substance extracted from tobacco leaves. When nicotine is absorbed in excessive amounts, it can lead to respiratory failure and cardiac arrest. The commercialization of electronic cigarettes (e-cigarettes) has allowed users to directly handle e-cigarette liquid. Consequently, the risk of liquid nicotine exposure has increased. We describe our experience of managing the case of a patient who orally ingested a high concentration of liquid nicotine from e-cigarette liquid. The patient presented with bradycardia and hypotension, which are symptoms of parasympathetic stimulation, together with impaired consciousness. He recovered following treatment with atropine and a vasopressor.

Nicotine intoxication by e-cigarette liquids: a study of case reports and pathophysiology

“…In terms of quantity, cotinine is the most stable metabolite and its concentration is considered directly proportional to the amount of nicotine absorbed [58]. However, according to reports on nicotine poisoning, clinical patterns and survival rates do not always associate with cotinine concentration [38]. Despite the consensus in literature on cotinine being a more reliable indicator of nicotine intoxication than nicotine itself, our results from e-liquid intoxications show the opposite.…”

“…In our dataset, the lethal nicotine concentration is between 800 and 1600 mg L À1 , which is 4.4-to 8.9-fold higher than the generally accepted lethal oral dose of 60 mg or less that would lead to a plasma concentration of approximately 180 mg L À1 [15]. This latter plasma concentration is an estimate, since there are individual differences in nicotine metabolism, due to genetic polymorphism and other interindividual differences [38]. For example, women generally metabolise nicotine more rapidly than men [51].…”

“…After oral ingestion, nicotine is absorbed by the mucosa in mouth and bowel and metabolised predominantly in the liver [55]. The first-pass effect decreases the bioavailability of nicotine by 30-40% [38]. Peak plasma concentrations are reached around 60 minutes after oral ingestion, however, in high dosages Tmax is potentially prolonged.…”

Severe Acute Toxicity of Inhaled Nicotine and e-Cigarettes

“…The intoxication signs we observed in animals during acute nicotine aerosol inhalation 8 are consistent with those of nicotine poisoning by e-liquid ingestion observed in patients. 3,4 Our studies show a link between inhaled nicotine and seizures as well as other life-threatening conditions such as respiratory depression and arrhythmia.…”

“…Seizures due to nicotine poisoning have been reported in intentional or accidental swallowing of nicotinecontaining e-liquid. 3,4 The median lethal dose for nicotine is 0.5 to 1 mg/kg body weight in adults. 5 Animal studies show that the median lethal dose for nicotine is 70 mg/kg (oral administration) 6 and 23.5 mg/kg (intraperitoneal injection) 7 in rats.…”