Nicotine may not have been the exact toxin, but it is close:
Nicotine is an alkaloid contained in the leaves of many species of plants,
but is usually obtained commercially from tobacco. A 14% preparation of the
free alkaloid is marketed as a greenhouse fumigant. Significant volatilization of
nicotine occurs. Commercial nicotine insecticides have long been known as
Black Leaf 40. This formulation was discontinued in 1992. Other currently
available formulations include dusts formulated with naphthalene and dried
blood used to repel dogs and rabbits. Be aware of Green Tobacco Syndrome
from dermal absorption. Very little nicotine insecticide is currently used in the
United States, although old preparations of nicotine insecticides may still be
found on occasion.6 Today, most nicotine poisonings are the result of ingestion
of tobacco products and incorrect use of nicotine skin patches.
Nicotine alkaloid is efficiently absorbed by the gut, lung, and skin. Extensive
biotransformation occurs in the liver with 70-75% occurring as a first pass
effect. 7 Both the liver and kidney participate in the formation and excretion of
multiple end-products, which are excreted within a few hours. Estimates of the
half-life of nicotine range from about one hour in smokers to as much as two
hours in non-smokers.8,9
Toxic action is complex. At low doses, autonomic ganglia are stimulated.
Higher doses result in blockade of autonomic ganglia and skeletal muscle neuromuscular
junctions, and direct effects on the central nervous system. Paralysis and
vascular collapse are prominent features of acute poisoning, but death is often due
to respiratory paralysis, which may ensue promptly after the first symptoms of
poisoning.Nicotine is not an inhibitor of the cholinesterase enzyme.
Signs and Symptoms of Poisoning
Early and prominent symptoms of poisoning include salivation, sweating,
dizziness, nausea, vomiting, and diarrhea. Burning sensations in the mouth and
throat, agitation, confusion, headache, and abdominal pain are reported. If dosage
has been high, vascular collapse with hypotension, bradycardia or other
arrythmias, dyspnea then respiratory failure, and unconsciousness may ensue
promptly.6,10,11,12 In some cases, hypertension and tachycardia may precede hypotension
and bradycardia, with the latter two signs leading to shock.11,12 Seizures
may also occur.6,11 In one case of ingestion of a large dose of nicotine
alkaloid pesticide, the patient developed asystole within two minutes. He later
developed seizures and refractory hypotension.6
Confirmation of Poisoning
Urine content of the metabolite cotinine can be used to confirm absorption
1. Skin decontamination. If liquid or aerosol spray has come in contact with
skin, wash the area thoroughly with soap and water. If eyes have been contaminated,
flush them thoroughly with clean water or saline. If irritation persists,
obtain specialized medical treatment.
If symptoms of poisoning appear during exposure to an airborne nicotine
insecticide, remove the person from the contaminated environment immediately,
wash any skin areas that may be contaminated, then transport the victim to the
nearest treatment facility. Although mild poisoning may resolve without treatment,
it is often difficult to predict the ultimate severity of poisoning at the onset.
2. Pulmonary ventilation. If there is any indication of loss of respiratory
drive, maintain pulmonary ventilation by mechanical means, using supplemental
oxygen if available, or mouth-to-mouth or mouth-to-nose methods if necessary.
Toxic effects of nicotine other than respiratory depression are usually
survivable. The importance of maintaining adequate gas exchange is therefore
3. Gastrointestinal decontamination. If a nicotine-containing product has
been ingested recently, immediate steps must be taken to limit gastrointestinal
absorption. If the patient is fully alert, immediate oral administration of activated
charcoal as outlined in Chapter 2 is probably the best initial step in management.
Repeated administration of activated charcoal at half or more the
initial dosage every 2-4 hours may be beneficial. Since diarrhea is often a part
of this poisoning, it is usually not necessary or appropriate to administer a
cathartic. Do not administer syrup of ipecac.
4. Cardiac monitoring. Monitor cardiac status by electrocardiography, and
measure blood pressure frequently. Cardiopulmonary resuscitation may
be necessary. Vascular collapse may require administration of norepinephrine
and/or dopamine. Consult package inserts for dosages and routes of administration.
Infusions of electrolyte solutions, plasma, and/or blood may also be
required to combat shock.
5. Atropine sulfate. There is no specific antidote for nicotine poisoning. Severe
hypersecretion (especially salivation and diarrhea) or bradycardia may be
treated with intravenous atropine sulfate.
Dosage of Atropine Sulfate:
• Adults and children over 12 years: 0.4-0.5 mg slowly IV, repeated every
5 minutes if necessary.
• Children under 12 years: 0.01 mg/kg body weight, slowly IV, repeated
every 5 minutes if necessary. There is a minimum dose of 0.1 mg.
6. Convulsions should be controlled as outlined in Chapter 2. If the patient
survives for four hours, complete recovery is likely.
"Acute nicotine toxicity is associated with over stimulation of nicotinic receptors. Burning in the throat with nausea and vomiting occurs quickly after ingestion. More toxic manifestations include cardiac tachyarrythmias, seizures, and hypertensive crisis. The lethal dose of nicotine in adults is from 0.5 to 1.0 mg/kg of body weight or a total dose of 30--60 mg. Toxic symptoms might been seen at doses as low as 2--5 mg of nicotine; however, persons might have widely different levels of tolerance to the toxic effects of nicotine. Small children might develop symptoms after exposure to as little as 1 mg of nicotine. Nicotine is used in a limited number of pesticides because of its toxic properties; nine nicotine-containing pesticides are registered for use in Michigan, and none of the product labels list nicotine at more than 14%. Black Leaf 40 contained 40% nicotine, and the EPA canceled its product registration in 1992 because of its toxicity."
2.2 Summary of clinical effects
Burning sensation in the mouth and throat, salivation, nausea, abdominal pain, vomiting and diarrhoea. Gastrointestinal reactions are less severe but can occur even after cutaneous and respiratory exposure.
Systemic effects include: agitation, headache, sweating, dizziness, auditory and visual disturbances, confusion, weakness and lack of coordination.
bradycardia, paroxysmal atrial fibrillation, or cardiac standstill may be observed. A transient increase in blood pressure, followed by hypertension,
In severe poisoning, tremor, convulsions and coma occur.
Faintness, prostration, cyanosis and dyspnoeaprogress to collapse. Death may occur from paralysis of respiratory muscles and/or central respiratory failure.
This would account for a person possibly going into a bathroom. It might not be bulimia - it would be a purging of toxins. A person might also have to be de-fibbed several times, and have the symptoms mentioned above. They might later have a high or off-the-chart rbc count in their urine. Who'd think of screening for nicotine?
A BP lowering drug could be added to cause an immediate event and to throw off the diagnosis. The purging would also get rid of most of the GI evidence - BUT - I recall reading that a certain patient presented with GI sounds.
It would be very dangerous for a person to drink a glass of ice tea with nicotine in it.