SMOKING CHINESE BROCCOLI? J.L. Yuh 1 , E. Yee 2 , A.G. Gomez 3 ; 1 Olive View±UCLA SFVP, Sylmar, CA; 2 VA Albuquerque±University of New Mexico, Albuquerque, NM; 3 University of California, Los Angeles, Sepulveda, CA (Tracking ID #75461) LEARNING OBJECTIVES: 1. Recognize acute nicotine in toxication 2. Discuss the management and treatment of acute nicotine intoxication CASE INFORMATION: A 56 year old Thai nun, non-smoker, with no known medical history was brought in for an acute onset of confusion, lethargy, and diffuse body weakness. Following breakfast, the patient was found to be minimally responsive next to a bowl of soup. By report, this soup contained many leaves of Chinese broccoli self-grown at the temple. In the ED, the patient's presenting GCS was 9, T 37.1F, pulse 49, BP 91/39, respirations 16, and room air O2 sat 94%. She was minimally responsive and diffusely flaccid on motor exam. IV fluids, NG charcoal lavage, and sorbitol were administered. CBC, CHEM 10, LFTs, and UA were all normal; serum/urine toxicology screen, acetaminophen and alcohol levels were negative. CXR was clear, and head CT did not show any shifts, masses, or bleeds. EKG showed only sinus bradycardia at 50 bpm. On repeat exam, pt was slightly more responsive since presentation, with pupils dilated and sluggish, but not following commands in English or Thai. She was admitted to the ICU for monitoring. Several leaves of the Chinese broccoli used in the soup were brought in later. Upon calling poison control and researching botanical atlases, it was determined to be a tobacco plant. Her serum nicotine level was low, while her serum cotinine level was high, indicating the metabolism of nicotine to cotinine, and confirming an ingestion of 15+ tobacco leaves. The patient regained her strength and alertness gradually and was discharged in normal health on day 3. The temple members subsequently removed all remaining`Chinese broccoli' plants! IMPLICATIONS/DISCUSSION: Nicotine overdose can result from overuse of cigarettes, nicotine gum or patches, and plant ingestion. It is seen most commonly in patients smoking while on a patch. Patients can exhibit weakness, convulsions, coma, respiratory distress/apnea, pupillary dilatation, abdominal cramps, vomiting, initial tachycardia/hypertension, followed by bradycardia/hypotension. Diagnosis is by careful history and physical exam as there are no set serum toxicity levels. The half-life of nicotine is 0.5±2 hours while that of cotinine (a better marker due to its slower clearance) is 12±30 hours. Management includes airway protection, charcoal lavage, sorbitol, hydration, and circulatory support. Symptoms can last several hours, and survival after 4 hours of intoxication usually prognosticates complete recovery. Lethargy may remain for several days. Caution needs to be emphasized for patients ingesting unknown plants and to remind patients of the dangers of using nicotine replacements while continuing to smoke.