Advertisement

Internet Suicide Guidelines: Report of a Life-Threatening Poisoning Using Tobacco Extract

      Abstract

      Background: Severe nicotine intoxication occurred in a patient after ingestion of a tobacco extract made from a recipe found on a freely available Internet site. Objectives: To determine the levels of nicotine and cotinine in the plasma of a patient who tried to commit suicide by drinking a highly concentrated tobacco extract. Case report: A 67-year-old man tried to commit suicide by following guidelines found on an Internet site. He soaked 300 grams of tobacco for 3 days in water, evaporated most of the extract, and drank the rest of it. He felt sick immediately, with the following signs: respiratory depression, hypothermia, hypersalivation, bradycardia, and myoclonic jerks. Soon after the ingestion he vomited most of the extract. Toxicological analysis revealed potentially life-threatening nicotine and cotinine serum concentrations. Surprisingly, nicotine peak levels (322 μg/L) and cotinine peak levels (9092 μg/L) were reached more than 3 h after ingestion of the extract. Estimated nicotine and cotinine half-lives were 200 min and 1185 min, respectively. Treatment consisted of gastric lavage, ventilation, and monitoring of vital functions. The patient recovered and was discharged from the Emergency Department 4 days later without sequelae. Conclusion: Nicotinergic intoxication is not always easy to recognize, and without clues from the patient and the toxicologic analysis, might well have been missed in the present case.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kozlowski L.
        • Mehta N.
        • Sweeney C.
        • et al.
        Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the United States.
        Tob Control. 1998; 7: 369-375
        • Connolly G.
        • Hillel R.
        • Wayne G.
        • Koh H.
        Trends in nicotine yield in smoke and its relationship with design characteristics among popular US cigarette brands, 1997–2005.
        Tob Control. 2007; 16: e5
        • Clarke M.
        Quantitation of nicotine in tobacco products by capillary electrophoresis.
        J AOAC Int. 2002; 85: 1-7
        • Saxena K.
        • Scheman A.
        Suicide plan by nicotine poisoning: a review of nicotine toxicity.
        Vet Hum Toxicol. 1985; 27: 495-497
        • Montalto N.
        • Brackett C.
        • Sobol T.
        Use of transdermal nicotine systems in a possible suicide attempt.
        J Am Board Fam Pract. 1994; 7: 417-420
        • Woolf A.
        • Burkhart K.
        • Caraccio T.
        • Litovitz T.
        Self-poisoning among adults using multiple transdermal nicotine patches.
        J Toxicol Clin Toxicol. 1996; 34: 691-698
        • Kemp P.
        • Sneed G.
        • George C.
        • Distefano R.
        Postmortem distribution of nicotine and cotinine from a case involving the simultaneous administration of multiple nicotine transdermal systems.
        J Anal Toxicol. 1997; 21: 310-313
        • Rogers A.
        • Denk L.
        • Wax P.
        Catastrophic brain injury after nicotine insecticide ingestion.
        J Emerg Med. 2004; 26: 169-172
        • Lavoie F.
        • Harris T.
        Fatal nicotine ingestion.
        J Emerg Med. 1991; 9: 133-136
        • Woolf A.
        • Burkhart K.
        • Caraccio T.
        • Litovitz T.
        Childhood poisoning involving transdermal nicotine patches.
        Pediatrics. 1997; 99: e4
        • Dempsey D.
        • Tutka P.
        • Jacob P.
        • et al.
        Nicotine metabolite ratio as an index of cytochrome P450 2A6 metabolic activity.
        Clin Pharmacol Ther. 2004; 76: 64-72
        • Benowitz N.
        • Jacob P.
        Metabolism of nicotine to cotinine studied by a dual stable isotope method.
        Clin Pharmacol Ther. 1994; 56: 483-493
        • Cashman J.
        • Park S.
        • Yang Z.
        • et al.
        Metabolism of nicotine by human liver microsomes: stereoselective formation of trans-nicotine N-oxide.
        Chem Res Toxicol. 1992; 5: 639-646
        • Nakajima M.
        • Yamamoto T.
        • Nunoya K.
        • et al.
        Characterization of CYP2A6 involved in 3-hydroxylation of cotinine in human liver microsomes.
        J Pharmacol Exp Ther. 1996; 277: 1010-1015
        • Nakajima M.
        • Yamamoto T.
        • Nunoya K.
        • et al.
        Role of human cytochrome P4502A6 in C-oxidation of nicotine.
        Drug Metab Dispos. 1996; 24: 1212-1217
        • Hukkanen J.
        • Jacob III, P.
        • Benowitz N.
        Metabolism and disposition kinetics of nicotine.
        Pharmacol Rev. 2005; 57: 79-115
        • Benowitz N.
        • Jacob P.
        Daily intake of nicotine during cigarette smoking.
        Clin Pharmacol Ther. 1984; 35: 499-504
      1. Higa de Landoni J. Nicotine. In: International Program on Chemical Safety (IPCS). Available at: http://www.inchem.org/documents/pims/chemical/nicotine.htm, 1990. Accessed June 2, 2008.

      2. Suicide FAQ. Available at: http://fringe.davesource.com/Fringe/Information/Suicide_FAQ.html. Accessed: June 2, 2008.

        • Metzler W.
        • Wronski R.
        • Bewig B.
        The lethal ingestion of cigarettes in adults: does it really exist [German]?.
        Dtsch Med Wochenschr. 2005; 130: 1491-1493
        • Lazutka F.
        • Vasiliauskene A.P.
        • Gefen S.
        On the toxicological assessment of the insecticide nicotine sulfate [Russian].
        Gig Sanit. 1969; 34: 30-33
      3. Ekwall B, Clemedson C. Time-related lethal blood concentrations from acute human poisoning of chemicals. Part 2: the monographs. No. 18 Nicotine. Available at: www.cctoxconsulting.a.se/18_Nicotine.pdf. Accessed June 2, 2008.

        • O'Loughlin J.
        • Paradis G.
        • Kim W.
        • et al.
        Genetically decreased CYP2A6 and the risk of tobacco dependence: a prospective study of novice smokers.
        Tob Control. 2004; 13: 422-428
        • Molander L.
        • Hansson A.
        • Lunell E.
        Pharmacokinetics of nicotine in healthy elderly people.
        Clin Pharmacol Ther. 2001; 69: 57-65
        • Zevin S.
        • Benowitz N.
        Drug interactions with tobacco smoking.
        Clin Pharmacokinet. 1999; 36: 425-439
        • Recupero P.
        • Harms S.
        • Noble J.
        Googling suicide: surfing for suicide information on the Internet.
        J Clin Psychiatry. 2008; 69: 878-888
        • Schön C.
        • Ketterer T.
        Asphyxial suicide by inhalation of helium inside a plastic bag.
        Am J Forensic Med Pathol. 2007; 28: 364-367
        • Gallagher K.
        • Smith D.
        • Mellen P.
        Suicidal asphyxiation by using pure helium gas: case report, review, and discussion of the influence of the internet.
        Am J Forensic Med Pathol. 2003; 24: 361-363