Title: Nicotine poisoning from liquid nicotine ingestion<br/>Author: Hong Kim<br/><a href='http://umem.org/profiles/faculty/526/'>[Click to email author]</a><hr/><p>
        Electronic cigarettes have been gaining popularity in the U.S. as a smokeless delivery system for nicotine. These devices require liquid nicotine (e-liquid) that are vaporized and inhaled (vaping).</p>
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        E-liquid can have nicotine concentration as high as 100 mg/mL, which are diluted prior to use. When ingested in high concentration and in sufficient volume (1 vial = 15 mL) patients can develop significant nicotinic toxicity.  Recently a case of cardiac arrest has been reported after ingesting two 15 ml vial (100 mg/mL).</p>
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        Nicotine mimics the effects of acetylcholine (Ach) release by binding to nicotinic receptors located in:</p>
<ul>
        <li>
                Brain</li>
        <li>
                Spinal cord</li>
        <li>
                Autonomic ganglia</li>
        <li>
                Adrenal medulla</li>
        <li>
                Neuromuscular junction</li>
        <li>
                Chemoreceptors of carotid/aortic bodies</li>
</ul>
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        Clinical manifestation of toxicity (similar to cholinergic toxidrome) is biphasic with early central stimulation followed by depression. (see table below)</p>
<table align="left" border="1" cellpadding="0" cellspacing="0">
        <tbody>
                <tr>
                        <td style="width:109px;">
                                <p>
                                         </p>
                        </td>
                        <td style="width:114px;">
                                <p>
                                        <strong>GI</strong></p>
                        </td>
                        <td style="width:125px;">
                                <p>
                                        <strong>Respiratory</strong></p>
                        </td>
                        <td style="width:126px;">
                                <p>
                                        <strong>Cardiovascular</strong></p>
                        </td>
                        <td style="width:117px;">
                                <p>
                                        <strong>Neurologic</strong></p>
                        </td>
                </tr>
                <tr>
                        <td style="width:109px;">
                                <p>
                                        <strong>Early (1 hr)</strong></p>
                        </td>
                        <td style="width:114px;">
                                <p>
                                        Nausea</p>
                                <p>
                                        Vomiting</p>
                                <p>
                                        Salivation</p>
                                <p>
                                        Abdominal pain</p>
                        </td>
                        <td style="width:125px;">
                                <p>
                                        Bronchorrhea</p>
                                <p>
                                        Hyperpnea</p>
                        </td>
                        <td style="width:126px;">
                                <p>
                                        Hypertension</p>
                                <p>
                                        Tachycardia</p>
                                <p>
                                        Pallor</p>
                        </td>
                        <td style="width:117px;">
                                <p>
                                        Agitation</p>
                                <p>
                                        Anxiety</p>
                                <p>
                                        Dizziness</p>
                                <p>
                                        Blurred vision</p>
                                <p>
                                        Headache</p>
                                <p>
                                        Hyperactivity</p>
                                <p>
                                        Tremors</p>
                                <p>
                                        Fasciculation</p>
                                <p>
                                        Seizures</p>
                        </td>
                </tr>
                <tr>
                        <td style="width:109px;">
                                <p>
                                        <strong>Late</strong></p>
                                <p>
                                        <strong>(0.5-4 hr)</strong></p>
                        </td>
                        <td style="width:114px;">
                                <p>
                                        Diarrhea</p>
                        </td>
                        <td style="width:125px;">
                                <p>
                                        Hypoventilation</p>
                                <p>
                                        Apnea</p>
                        </td>
                        <td style="width:126px;">
                                <p>
                                        Bradycardia</p>
                                <p>
                                        Hypotension</p>
                                <p>
                                        Dysrhythmias</p>
                                <p>
                                        Shock</p>
                        </td>
                        <td style="width:117px;">
                                <p>
                                        Lethargy</p>
                                <p>
                                        Weakness</p>
                                <p>
                                        Paralysis</p>
                        </td>
                </tr>
        </tbody>
</table>
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        <strong>Management:</strong> There is no specific antidote or reversal agent. The management of nicotine toxicity focuses on organ-specific dysfunction. </p>
<div>
        e.g. bronchorrhea = atropine; apnea = intubation; seizure = benzodiazepine.</div>
<fieldset><legend>References</legend>

                <ol>
        <li>
                Chen BC et al. Death following intentional ingestion of e-liquid. Clin Toxicol 2015;53:914-916.</li>
        <li>
                Kim JW et al. Liquid nicotine toxicity. Pediatr Emer Care 2015;31:517-524.</li>
</ol>
</fieldset>