See also

Poisoning – Acute guidelines for initial management

For advice contact the Victorian Poisons Information Centre on 13 11 26 (24 hours a day, seven days a week)

Key points 

1. Mild nicotine exposures may result in gastrointestinal symptoms only
2. Larger doses may be rapidly absorbed and can cause severe toxicity resulting in seizures, cardiovascular collapse and coma
3. Liquid nicotine solutions used in e-cigarette devices are often highly-concentrated. Small volumes may cause life-threatening toxicity in children
   

Background

Nicotine is highly toxic and rapidly absorbed after either ingestion or inhalation.  

Poisoning occurs through initial stimulation and ultimate blockade of the nicotinic acetylcholine receptor. 

Initial stimulatory effects occur within minutes and may include agitation, diaphoresis, nausea and vomiting, tachycardia, bronchoconstriction and seizures. At higher doses, a second phase involving bradycardia, hypotension, respiratory failure and coma may supervene 1 to 4 hours after exposure. 

Any ingestion may cause mild toxicity. The minimum potentially lethal dose is reported to be anything greater than 0.5 mg/kg. Any child ingesting more than one whole cigarette or more than three butts requires medical assessment. The quantity of nicotine in various products is shown below. 

*note: e-cigarette devices and liquid nicotine solutions remain unregulated in Australia. As such, product labels are unreliable and true nicotine concentrations have been shown to vary widely.

Patients requiring assessment

• Urgent assessment is required for all children who may have ingested the following:
  • ANY quantity of liquid nicotine
  • More than one whole cigarette
  • More than three butts
• Any symptomatic patient
• All patients with deliberate self-poisoning or significant accidental ingestion 
  

Risk Assessment

History

• Determine if intentional ingestion/overdose or accidental
• Method of exposure – ingestion of filtered cigarette or butt, liquid nicotine, gum/lozenge, patch or exposure by inhalation.
• Calculate likely nicotine dose in mg/kg. (note: it may  be difficult to determine true concentration of imported liquid nicotine products)
• Consider co-ingestants, eg: paracetamol

Examination

Early clinical signs (<1 hour)

• Gastrointestinal – nausea and vomiting, abdominal pain, salivation
• CVS – tachycardia, hypertension
• Respiratory – shortness of breath, bronchorrhoea, bronchoconstriction / wheeze
• Neurologic – agitation, fasciculation, seizures
  

Late clinical signs in larger exposures (1 to 4 hours)

• CVS – bradycardia, arrhythmia, hypotension, shock
• Respiratory – hypopnoea, apnoea
• Neurologic – lethargy, muscle paralysis, stupor, coma
  

Investigations

For all symptomatic patients:

• ECG: initially and repeat at 4 hours until normal.  
• Pathology: nil specific
  

Acute Management

Most cases of exposure will be low-risk and management is supportive. For higher-risk exposures, consider:

1. Resuscitation

• Standard procedures and supportive care, including cardiorespiratory monitoring.
• Hypotension, symptomatic bradycardia and respiratory failure should be treated as per standard resuscitation guidelines.
  

2. Decontamination

• Activated charcoal is very rarely indicated. A dose of 1 g/kg may be recommended in high-risk cases who present early. Discuss with toxicologist.
• For significant skin exposure – wash affected area with soap and water
  

Ongoing care and monitoring

Patients who are either asymptomatic following exposure or who are recovering from gastrointestinal symptoms only should be monitored for 4 hours prior to discharge.

Consider consultation with the local paediatric team when

Admission should be considered for all children with signs or symptoms of a larger exposure and for adolescent patients with an intentional overdose.

Consult Contact Victorian Poisons Information Centre 13 11 26 for advice

Consider transfer when

• All patients with significant ingestions or who have required initial resuscitation.
• For advice and inter-hospital transfer (including ICU level) ring the Sick Child Hotline (PIPER): 9345 7007
  

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Consider discharge when

Normal GCS 
Normal ECG
Period of observation as above
For deliberate ingestion. A risk assessment should indicate that the patient is at low risk of further self-harm in the discharge setting

Discharge information and follow-up

Poisoning prevention for children Parent information

Victorian Poisons Information Centre: 13 11 26 www.austin.org.au/poisons

Intentional self harm: Referral to local mental health services e.g. Orygen Youth Health: 1800 888 320 

Recreational poisoning: Referral to YoDAA, Victoria's Youth Drug and Alcohol Advice service: 1800 458 685