Cyanide Poisoning


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  • Cyanide Poisoning

    1. 1. “ Cyanide Poisoning: An Old Enemy with New Risks” By Mary Jo Koschel, MSN,CFRN, NREMT-P PVH EMS Paramedic Clinical Coordinator North Colorado Med Evac, Flight Nurse
    2. 2. A notorious poison used repeatedly throughout the centuries…. <ul><li>First century Roman Emperor Nero used cherry laurel to kill his enemies. </li></ul><ul><li>France in World War I </li></ul><ul><li>Japan in World War II </li></ul><ul><li>Nazis gas chambers </li></ul><ul><li>Iraq in the 1980’s </li></ul><ul><li>1993 World Trade Center bombing </li></ul><ul><li>1995 Tokyo subway attack </li></ul><ul><li>2002 plot American Embassy in Rome </li></ul><ul><li>2002 “Dr. Chaos” amassment of >1 pound of cyanide in the Chicago subway system </li></ul><ul><li>2003 cyanide murder of a Baltimore teenager </li></ul>
    3. 3. Cyanide and Fire Smoke <ul><li>NFPA and USFA stats indicate that hydrogen cyanide is an important cause of smoke-inhalation morbidity and mortality- is usually a mix of CO and lethal blood concentrations of cyanide. </li></ul><ul><li>5000-10,000 deaths per year in the US from smoke inhalation. </li></ul>
    4. 4. Case in point….. <ul><li>March 2006, Providence, Rhode Island, restaurant fire where a large amount of Styrofoam insulation burned. </li></ul><ul><li>5 firefighters tested positive for cyanide poisoning. </li></ul>
    5. 5. Mechanism of Cyanide Poisoning <ul><li>Cyanide prevents cells from using oxygen by inhibiting the oxidative function of mitochondrial cytochrome oxidase which is essential to aerobic cellular function…… </li></ul><ul><li>Cyanide poisoning is caused by the inability of the cells to use oxygen rather than by deficient oxygen delivery or supply. </li></ul>
    6. 7. Routes of exposure…. <ul><li>Cyanides in the gaseous form can be absorbed into the body through inhalation. </li></ul><ul><li>In the liquid or solid forms, they can be swallowed accidentally or intentionally. </li></ul><ul><li>Absorption through the skin can be significant if there is extensive exposure or when the skin is abraded. </li></ul>
    7. 8. Symptoms of Acute Cyanide Poisoning <ul><li>Immediate marked symptoms resulting in death within minutes. </li></ul><ul><li>Paris Fire Brigade 1995-2003 looked at 101 patients treated for smoke inhalation-associated cyanide poisoning …….37.6% found in cardiac arrest and 45.5% were neurologically impaired. </li></ul>
    8. 9. So why aren’t we tripping over all the dead bodies from cyanide poisoning???
    9. 10. Factors effecting symptomolgy <ul><li>Extent of exposure </li></ul><ul><li>Concentration of exposure </li></ul><ul><li>Variability in absorption and the solubility of the cyanide salts ingested </li></ul><ul><li>Pre-existing levels of cyanide exposure </li></ul><ul><ul><li>cigarette smokers, ingestions of cyanogenic foods </li></ul></ul><ul><li>Liver function </li></ul><ul><ul><li>Disease reduces the ability to process cyanide </li></ul></ul><ul><li>Presence of Vitamin B12(hydroxocobalamin) in the system </li></ul>
    10. 11. Early symptoms <ul><li>Hypertension with reflexive bradycardia </li></ul><ul><li>Faintness, confusion, headache and anxiety </li></ul><ul><li>Tachypnea and dyspnea </li></ul><ul><li>Other non-specific symptoms include bright red retinal veins secondary to elevated venous oxygenation, bitter almond odor of breath or gastric contents, bright cherry red complexion, and absence of cyanosis. </li></ul>
    11. 12. Severe cyanide poisoning is manifested by hypotension, seizures, coma, respiratory depression, cardiovascular collapse and cardio respiratory arrest……not very specific……so when do we treat for cyanide poisoning?
    12. 13. Presumptive diagnosis…. <ul><li>Suspicion of exposure and clinical presentation…rapid loss of consciousness, coma or CV instability… </li></ul><ul><li>HALLMARK lab finding </li></ul><ul><li>is metabolic acidosis with markedly elevated plasma lactate(>8 mmol/L) and excessive venous oxygenation.. </li></ul><ul><li>No field test is available! </li></ul>
    13. 14. Management options
    14. 15. Remove from exposure… <ul><li>BLS with 100% oxygen delivery and CPR as indicated. </li></ul><ul><li>ALS with definitive airway and IV established, standard ACLS protocols for dysrhythmia treatment, Sodium bicarbonate for metabolic acidosis, and anticonvulsants for seizures. </li></ul><ul><li>Prompt Antidotal Treatment: </li></ul><ul><li>1) Cyanide Antidote Kit </li></ul><ul><li>This is probably going away </li></ul><ul><li>2) Hydroxocobalamin </li></ul><ul><li>The “new” kid on the block! </li></ul>
    15. 16. Cyanide Antidote Kit- <ul><li>Amyl nitrite pearls to initiate methemoglobin (~3%) that attracts the cyanide ions. </li></ul><ul><li>Sodium nitrite IV to further bind the cyanide (forms 20-30% methemoglobin) and liberate the cytochrome oxidase. </li></ul><ul><li>Sodium thiosulfate IV converts cyano-methemoglobin to excretable thiocyanate. </li></ul>CH3>CHCH2CH2ONO CH3 Amyl nitrite
    16. 17. Cyanide Antidote Kit not generally recommended in smoke-inhalation victims… <ul><li>Nitrite –induced methemoglobinemia superimposed on carboxyhemoglobinemia from carbon monoxide exposure with smoke inhalation could lead to potentially fatal reduction in the oxygen-carrying capacity of the blood. </li></ul><ul><li>3 step process, IV calculations are mL/kg based </li></ul><ul><li>Need to have methylene blue available for nitrite poisoning. </li></ul>
    17. 18. Introducing Hydroxocobalamin This is the future of Cyanide Exposure Treatment
    18. 19. Properties of Hydroxocobalamin <ul><li>Mechanism of Action </li></ul><ul><li>History </li></ul><ul><li>Clinical Profile </li></ul><ul><li>Administration </li></ul><ul><li>Chelates cyanide to form cyanocobalamin = </li></ul><ul><li>Vitamin B12 </li></ul><ul><li>Licensed in France 1996 and licensed in US December of 2006 </li></ul><ul><li>Empiric use in France </li></ul><ul><li>Well tolerated with only rare allergic rxns and no major toxicities </li></ul><ul><li>IV with adult dose=5 Grams, weight-based in peds. </li></ul>
    19. 20. Clinical course post-poisoning… <ul><li>Monitor for ischemic cardiac and brain damage. </li></ul><ul><li>Parkinsonian syndrome may develop days to months after exposure with impaired motor reaction, reduced verbal fluency, slowed speech and retropulsion. </li></ul><ul><li>MRI shows basal ganglia abnormalities. </li></ul><ul><li>Treated with dopamine agonists and may moderate symptoms. </li></ul>
    20. 21. Monthly Points To Ponder (MPTP)… <ul><li>Cyanide exposure under-appreciated. </li></ul><ul><li>Heightened risks in smoke-inhalation exposures in the western world and post-911 terrorist concerns. </li></ul><ul><li>Ease of availability – check out poison-hunting of eBay! </li></ul><ul><li>Potential industry exposure in our service areas? </li></ul>
    21. 22. Scenario… <ul><li>11 y/o child with decreased LOC </li></ul><ul><li>Stable BP </li></ul><ul><li>Tachycardia </li></ul><ul><li>Tachypnea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Pulse ox sat 92% on 10 l O2 per mask </li></ul><ul><li>Lung Sounds clear to auscultation, HS nl S1S2-pediatric tachycardia </li></ul>
    22. 23. Scenario continued… <ul><li>PCO2 of 35, PO2 of 380, </li></ul><ul><li>but acidotic… </li></ul><ul><li>Was recently in greenhouse on grandfather’s tulip farm </li></ul><ul><li>Differentials???? </li></ul><ul><ul><li>Cyanide </li></ul></ul><ul><ul><li>OGPs </li></ul></ul><ul><ul><li>Nitrates </li></ul></ul><ul><ul><li>MUDPILES… </li></ul></ul><ul><li>Have to anticipate and be prepared to treat all of this! </li></ul>
    23. 24. Conclusion <ul><li>“ Where there is smoke, there may be cyanide…..” </li></ul>