This is on nicotine poisoning and twitching....
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Forwarded message:
From:   [log in to unmask] (Tebay, Wendy)
To:     [log in to unmask] (athome)
Date: 95-06-28 08:32:04 EDT
 
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Confirmation of Nicotine Poisoning
 
Urine content of the metabolite cotinine can be used to confirm absorption
of nicotine.
 
 
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Manifestations of Nicotine Poisoning
 
Early symptoms of poisoning are salivation, nausea, vomiting, and diarrhea.
Burning sensation in the mouth and throat and abdominal pain are reported.
If dosage has been high, vascular collapse, dyspnea then respiratory
failure, cyanosis, and unconsciousness may ensue promptly. Agitation,
sweating, headache, pupillary constriction, dizziness, incoordination,
confusion, weakness, tremor, and convulsions occur early in less fulminant
poisoning. Initial hypertension is probably due mainly to generalized
vasoconstriction. Subsequent shock is caused by vasodilatation, often
associated with vagotonic asystole or severe cardiac arrhythmias.
Respiratory failure is caused mainly by paralysis of the muscles of
respiration.
 
 
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Source and Products
 
Nicotine is an alkaloid contained in the leaves of many species of plants,
but is usually obtained commercially from tobacco. A 95% solution of the
free alkaloid in organic solvent has been marketed in the past as a
greenhouse fumigant. Another product used for the same purpose is a 40%
aqueous solution of nicotine sulfate. Significant volatilization of
nicotine occurs from both products. Commercial nicotine insecticides have
long been known as Black Leaf 40. Formulations include sprays and dusts.
Very little nicotine insecticide is used in the United States today; in
fact, most nicotine poisonings are the result of ingestion of tobacco
products.
 
 
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Toxicology of Nicotine
 
Nicotine alkaloid is efficiently absorbed by the gut, lung, and skin. The
sulfate salt is absorbed by lung and gut, but is poorly absorbed across the
skin. Extensive biotransformation occurs in the liver resulting in a
residence half-life of two hours or less. Both the liver and kidney
participate in the formation and excretion of multiple end-products, which
are excreted within a few hours.
 
Toxic action is complex, involving both stimulation and blockade of
autonomic ganglia and skeletal muscle neuromuscular junctions, as well as
direct effects on the central nervous system. Paralysis and vascular
collapse are prominent features of acute poisoning, but death is usually
due to respiratory paralysis, which may ensue promptly after the first
symptoms of poisoning. Nicotine is not a inhibitor of cholinesterase
enzyme.
 
 
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Treatment of EXTERNAL Nicotine Toxicosis
 
1. If liquid or aerosol spray has come in contact with skin, wash the area
thoroughly with soap and water.
 
2. If eyes have been contaminated, flush them thoroughly with clean water
or saline. If irritation persists, obtain specialized medical treatment.
 
3. 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.
 
4. If there is any indication of loss of respiratory drive, MAINTAIN
PULMONARY VENTILATION by mechanical means, including supplemental OXYGEN,
if available, by 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 paramount.
 
 
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Treatment of Nicotine Toxicosis by INGESTION
 
1. If a nicotine-containing product has been ingested, immediate steps must
be taken to limit gastrointestinal absorption:
 
A. IF the patient is fully ALERT, immediate oral administration of
ACTIVATED CHARCOAL is probably the best initial step in management.
 
Dosage of ACTIVATED CHARCOAL: Adults and children over 12 years: 50-100 gm
in 300-800 ml water.
 
Children under 12 years: 15-30 gm in 100-300 ml water. Because nicotine
itself is very likely to induce diarrhea, it is usually not appropriate to
include cathartic with the charcoal.
 
CAUTION: Because unconsciousness may develop rapidly in nicotine poisoning,
it is essential to position the patient after the charcoal slurry has been
swallowed (recumbent prone, head down) so that vomited material will not be
aspirated.
 
B. If the patient is unconscious or confused, the stomach should be emptied
by INTUBATION, ASPIRATION, and LAVAGE, after all precautions have been
taken to protect the respiratory tract from aspirated stomach contents (see
  Organophosphates, Treatment, Section 5). Charcoal slurry should be used
in washing the stomach, and several ounces should be left in the stomach
after the lavage. Repeated administration of activated charcoal at half or
more the initial dosage every 2-4 hours may be beneficial.
 
C. DO NOT administer Syrup of Ipecac. It may enhance medullary depressant
effects of nicotine, and may induce vomiting when the patient is obtunded.
 
2. Monitor cardiac status by electrocardiography, and measure blood
pressure frequently. Cardiopulmonary resuscitation may sometimes 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.
 
3. There is no specific antidote for nicotine poisoning. Severe
hypersecretion (especially salivation and diarrhea) may be controlled by
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.
 
CAUTION: Careful ECG monitoring of cardiac rhythm should accompany
intravenous administration of atropine.
 
4. Convulsions should be controlled with diazepam or other benzodiazepine
drug. See
  Solid Organochlorine Insecticides, Treatment, Section 4 for appropriate
dosages and administration.
 
5. If the patient survives for four hours, complete recovery is said to be
likely.
 
 
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