Poster 138: Hypoxic-Ischemic brain injury in a child secondary to acute nicotine intoxication due to ingestion: a case report.

Abstract

Setting: Tertiary care pediatric hospital. Patient: A 9-month-old white female. Case Description: The patient presented via ambulance after being found unresponsive at home and in respiratory distress of unknown inciting event. She required cardioresuscitative medications en route. On arrival, the patient was unresponsive, febrile, tachycardic, hypoxic, and hypotensive. Brain computed tomography was negative. Metabolic and rule-out sepsis work-ups were negative. Urine toxicology was positive for nicotine and caffeine. Brain magnetic resonance imaging performed on day 7 showed significant parenchymal volume loss. The patient was transferred to the inpatient pediatric rehabilitation unit after 3 weeks with continued generalized hypotonia, decreased arousal, and visual impairment. On reviewing the patient’s history, it was determined that her clinical presentation and resultant hypoxic-ischemic brain injury were likely secondary to acute nicotine intoxication. Toxicology was consulted and confirmed that the patient’s nicotine levels were consistent with ingestion, not second-hand smoke inhalation. Child abuse work-up revealed a healing tibial fracture. Assessment/Results: The patient slowly improved, acquiring purposeful use of her extremities, more consistent visual tracking, and resumption of near-normal for age verbalization. Discussion: Poisonings in the pediatric population are the third most common cause of unintentional morbidity in the toddler age group. The lethal oral dose of nicotine in adults is 40 to 60mg. Children are more sensitive to the effects of ingested nicotine, with as little as 1mg causing systemic symptoms in toddlers. Symptoms of acute ingestion include nausea, vomiting, confusion, and agitation. Lethargy, hypotonia, convulsions, vascular collapse, and coma may follow severe exposures. Death can occur secondary to respiratory failure and vascular collapse within 1 to 2 hours postingestion. Conclusion: Nicotine toxicity secondary to acute ingestion in the pediatric population presents serious complications, including hypoxic-ischemic brain injury. Parents who smoke cigarettes should be educated regarding the serious risks of nicotine ingestion.