What are the symptoms and treatment of nicotine toxicity?

Symptoms of Nicotine Toxicity

Nicotine toxicity presents with a characteristic biphasic pattern of nicotinic and muscarinic symptoms affecting multiple organ systems, with initial sympathetic stimulation followed by parasympathetic effects. 1

Cardiovascular Manifestations

• Initial nicotinic sympathetic hyperstimulation causes tachycardia and hypertension, followed by muscarinic activation leading to bradycardia, heart block, QT prolongation, arrhythmias, and hypotension 1
• Palpitations and irregular heartbeat are common presenting symptoms 2
• Blood pressure fluctuations occur throughout the toxic course 3

Gastrointestinal Symptoms

• Nausea and vomiting are among the most common and earliest symptoms 1, 3, 2
• Hypermotility causes abdominal cramps and severe diarrhea through muscarinic effects 1, 3
• These symptoms often appear immediately after exposure 4, 5

Neurological Effects

• Central nervous system toxicity manifests as seizures, coma, and respiratory depression 1
• Dizziness, headache, and weakness are frequent early symptoms 3, 2, 6
• Agitation and nervous twitching may occur in the initial phase 7, 6
• Myoclonic jerks can develop in severe cases 4

Respiratory System

• Laryngeal and upper airway irritation with congestion 1
• Bronchorrhea and bronchospasm from muscarinic effects 1
• Respiratory muscle paralysis from nicotinic effects represents a life-threatening complication 1
• Breathing difficulty is a concerning symptom requiring immediate attention 3
• Pulmonary edema may develop 1

Musculoskeletal Manifestations

• Involuntary fasciculations followed by weakness and flaccid paralysis result from nicotinic receptor overstimulation 1
• This progression reflects the depolarization block at the neuromuscular junction 1

Autonomic and Secretory Effects

• Excessive lacrimation, salivation, and perspiration from muscarinic hyperstimulation 1, 3
• Urinary incontinence may occur 1
• Pallor and chills are common 3, 8

Pediatric Considerations

Children are particularly vulnerable to nicotine toxicity through multiple exposure routes including ingestion, inhalation, and dermal absorption. 1, 3

• Dermal exposure (Green Tobacco Sickness) is common in children working on tobacco farms, with symptoms from moist tobacco plant absorption 3
• One child described the experience as feeling "like I was going to die" 3
• Symptoms in children are generally mild and resolve within 12 hours, though large exposures can be fatal 1

Clinical Course and Timing

• Symptoms typically appear immediately after exposure 4, 5, 8
• Peak nicotine levels may be delayed more than 3 hours after ingestion in some cases 4
• The elimination half-life is relatively short (less than 1-3 hours), meaning if patients survive the acute phase, prognosis is generally good 5
• Most cases resolve within 24 hours with appropriate supportive care 7, 8

Critical Pitfall

The biphasic nature of nicotine toxicity means initial sympathetic symptoms (tachycardia, hypertension) can mislead clinicians before the more dangerous parasympathetic phase (bradycardia, respiratory depression) develops. 1 Continuous monitoring is essential even when initial symptoms appear mild, as progression to life-threatening respiratory muscle paralysis and cardiovascular collapse can occur rapidly. 1, 4