Bradicardia sintomática causada por intoxicação por nicotina / Symptomatic bradycardia due to nicotine intoxication

RESUMO A nicotina é uma substância perigosa, extraída das folhas de fumo. Quando absorvida em quantidade excessiva, ela pode levar à insuficiência respiratória e à parada cardíaca. A comercialização de cigarros eletrônicos (e-cigarros) permite que os usuários manuseiem diretamente o líquido, com consequente aumento do risco de exposição à nicotina líquida. Descrevemos nossa experiência no tratamento do caso de um paciente que ingeriu elevada concentração de nicotina líquida contida em líquido para e-cigarros. O paciente apresentava bradicardia e hipotensão, que são sintomas de estimulação parassimpática, além de comprometimento da consciência. O paciente teve recuperação após tratamento com atropina e vasopressor.

ABSTRACT Nicotine is a dangerous substance extracted from tobacco leaves. When nicotine is absorbed in excessive amounts, it can lead to respiratory failure and cardiac arrest. The commercialization of electronic cigarettes (e-cigarettes) has allowed users to directly handle e-cigarette liquid. Consequently, the risk of liquid nicotine exposure has increased. We describe our experience of managing the case of a patient who orally ingested a high concentration of liquid nicotine from e-cigarette liquid. The patient presented with bradycardia and hypotension, which are symptoms of parasympathetic stimulation, together with impaired consciousness. He recovered following treatment with atropine and a vasopressor.

Diagnosis and Management of Green Tobacco Sickness

Nicotine is a liquid alkaloid present in tobacco leaves at a 1~6% concentration. Green tobacco sickness is an occupational illness caused by absorption of nicotine through skin exposed to wet tobacco leaves. It occurs throughout the world in tobacco-growing areas. The almost universal symptoms of weakness, nausea, vomiting, diarrhea, and dizziness may be confused with pesticide poisoning or heat stress illness. Since its recognition in the 1970s, green tobacco sickness is self-limited, usually lasting 1 to 2 days. There is no antidote, so treatment is supportive (for example, intravenous fluids for hypotension, antiemetics). The diagnosis can beconfirmed by measuring the nicotine concentration in the serum or urine, but its half-life is only 3~4 hours. Cotinine, the major nicotine metabolite, has a half-life of 36 hours, and thus is more useful. Young workers may be at higher risk for green tobacco sickness. Tobacco use is thought to offer weak protection by inducing tolerance. Handling tobacco that is wet from rain or dew increase the risk of green tobacco sickness. Repeated daily exposure over more than a week may also increase the risk. Green tobacco sickness is preventable by use of protective clothing and by avoiding skin contact with wet tobacco. When clothing becomes wet from environmental dampness or sweating, it should be changed to maintain an effective barrier. The best treatment is avoidance of poisoning : in addition to wearing gloves, long pants and a full shirt, workers picking or handling tobacco leaves should clean their hands frequently.