Symptoms and signs of acute overdosage:
(1) nausea, vomiting, hiccups, dry mouth, dyspepsia, diarrhea, lacrimation, salivation
(2) cyanosis, hyperventilation, apnea, increased bronchial secretions, respiratory depression
(3) insomnia, headache, ataxia, dementia, mental confusion, lightheadedness, seizures
(4) hyponatremia, hyperglycemia, methemoglobinuria
(5) blurred vision, nystagmus, mydriasis, ototoxicity, tinnitus, dysosmia (defect in smell)
(6) myalgia, abdominal pain, myoclonus, muscle fasciculations/paralysis, paresthesias, myasthenia, hypotonia, hyperreflexia, agitation
(7) hyperthermia
(8) AV block, tachycardia, hypertension, bradycardia (later), hypotension (later), atrial fibrillation, cardiac arrest
Criteria for hospital admission:
(1) pediatric ingestion:
(1a) > 2 whole cigarettes
(1b) > 6 cigarette butts
(1c) > 10 pieces of nicotine gum
(1d) a whole cigar or more
(1e) mouthful of chewing tobacco
(1f) nicotine patch
(1g) nicotine-containing insecticides
(1h) >= 40 mg nicotine total
(2) patients with tachycardia or hypertension more than 4 hours after exposure
(3) change in mental status, seizure activity
(4) cardiopulmonary complaints (cyanosis, respiratory depression, apnea, AV block, severe hypertension or hypotension, etc.)
(5) methemoglobin levels > 30%
Patients with methemoglobin levels < 30% may be discharged after 6 hours of observation if methemoglobin levels are < 15%.
Management of an acute overdosage:
(1) the airway should be maintained, with supplemental oxygen as needed
(2) empty gastric contents and administer activate charcoal
(3) provide cardiac monitoring in moderate to severe cases
(4) wash exposed skin
(5) atropine can help control excessive bronchial secretions, salivation or diarrhea
(6) seizures may be controlled with barbiturates or diazepam
(7) mechanical ventilation may be required for severe respiratory depression
Prognostic features:
(1) Survival after 4 hours is usually associated with complete recovery.
(2) The absence of vomiting predicts a favorable outcome.
