intoksikasi sianida

1. Medical Faculty of
Trisakti University
Jakarta
Cyanide Intoxication

2. Background
Many substances that may cause someone experiencing a
poisoned until it brings a death.
Substances that active chemically and physiology in one
body, at the point of certain dose (toxic) will bring an
unhealthiness or may cause a death.
Forensic discuss about toxic substance from its varies,
symptoms caused, and method forensic examination to
handle either for alive or dead victims.

3. Scope of Matters
Toxicology definition and factors that affect toxicity
Epidemiology, signs and symptoms, pharmacokinetic,
laboratory examination, and treatment/therapy of cyanide
poisoning
Forensic examination of patient that experiencing common
poison and cyanide poison
medikolegal aspects of deliberate poisoning or
unintentionally
Example case of cyanide poisoning

4. Toxicology Definition
As a part of medical science that focused on toxic
Study about nature and mechanism of toxic effect, varies
substance towards living things and other biologic system
A study about source, characteristic and a savor from toxic,
indication and treatment against poisoning and other
abnormality found in dead victim

5. Toxic Definition
A substance that may cause bad effect when it gets into a
body of a living things, either intentionally or unintentionally

6. Toxic
Origin:
Plants (opium, cocaine, curare, aflatoxin)
Animals (poison/snake toxin, spider/marine animals)
Mineral (arsenic, plumbum, and things that made from
synthetic)
Heroin

7. Toxic
Venue:
Nature-free (poison gas in nature, household)
Poison agriculture (insecticides, herbesida, pesticides)
Toxic industrial laboratories and industry
(acid and strong base, heavy metals)
Toxic food(CN in cassava, botulinus toxic, preservative,
additives substance and toxic in the form of medicine e.g.
sedative hypnotic)

8. Toxic
Organs that affected:
• Hepatotosik
• Nephrotoxic
Work mechanism:
• Toxic that bind sulfhydryl group (Pb)
• Effect on ATP-ase
• Forming methemoglobin (nitrate and nitrite)
The effects:
• Local
• Systemic
• local-systemic

9. Exposure to toxic substances on humans and
living things:
regular consumption
exposure from work
environmental exposure and poisoning, either intentionally
or unintentionally

10. Factors that affect poisoning:
How to enter:
Age
Body condition
Habits
Idiosinkrasi and allergic to vitamin E, penicilin, streptomycin
dan procaine
Time delivery

11. Cyanide
A deadly toxic substance
• Effects are very fast and can cause death within a
few minutes
• Hydrogen cyanide (formonitrile)
• In the form of liquid -> prussit acid and hydrocyanic acid
• Liquids can also be colorless or pale blue at the
temperature of normal room
• volatile and flammable
• diffuse either by air and explosives
• Very easy to mix with water
• Otherforms: sodium cyanide and potassium cyanide
(powder and white)

12. Epidemiology
• a major contributor
to morbidity and mortality, observed in approximately 5,000
to10,000 deaths occur from inhaling fog each year in the united
states
• Exposure suicide rarely reported to poison centers and
18 of 242 (in 2007) and 25 of238 (in 2008) cases
of cyanide poisoning is deliberate exposure as reported to the
American Association of Poison Control Centers
• fatal suicide in adult patients may easily be associated with sudden
death from
myocardial infarction, pulmonary embolism, or ventricular dysrhy
thmias

13. Source
Low-dose in nature and in every product that we
usually eat or use
Cyanide can be produced by bacteria, fungi and algae
Cyanide is found in cigarettes, motor vehicle
fumes, and food and the synthetic product
Cyanide in seed plants,especially grains (cassava wild, wild tu
bers, Intersection buffoonery,
wild cherry, plum, apricot, wild amigdalin,
jetberry bush, etc.)

14. Exposures
Fog Inhalation
Intentional poisoning (suicide)
Industry exposure
Iatrogenic exposure
Consumption of Supplements Containing Cyanide
(Uncommon)

15. Pharmacokinetic
Cyanide in the body will inactive some oxidative enzymes radically the
whole system, especially cytochrome oxidase by binding
to the ferric heme group from the oxygen carried by blood
The process of oxidation and reduction occurs as follows:
Cytochrome oxidase Fe + + Fe + + + cytochrome oxidase
+
CN
/---- Fe + + + cytochrome oxidase-cyanide-
Oxidize cyanide d in the body get into
cyanates and sulfosianat and expelled from the body through urine.
Toxic dose orally for HCN is 60-90 mg, while doses toxic to KCN or
NaCN is 200 mg.

16. Signs and Symptoms
Main effects: hypoxia system arise progressively
Symptoms and physical signs that found are depend on the
• The dose of cyanide
• Number of exposures
• Type of exposure
• Types of cyanide component
symptoms in the body:
• blood pressure, vision, lung, central nerve, heart, endocrine system,
autonomic system and metabolic system
• sore eyes because of irritation and difficulty breathing due to irritate
the respiratory tract mucosa
• high concentrations only within 15 seconds hiperpnea, 15 seconds to lose
consciousness. 3 minutes of apnea is a period of 5-8 minutes will cause the
heart muscle activity is hampered due to hypoxia and ends with death

17. • Exposure of hydrogen cyanide may cause irritation against eyes
and skin immediately after exposure or at least 30 to 60 minutes
In low concentrations, the effects of cyanide emerging about 15-
30 minutes later
 Early signs of cyanide poisoning:
• Temporary hiperpnea
• Headache
• dyspnea
• Anxiety
• Changes in behavior such as agitation and restlessness
• Sweating a lot, reddish skin color, body feels weak and vertigo

18. • cyanosis of the face, the foam out from the mouth,
rapid and weak pulse, rapid breathing
and sometimes irregular, dilated pupils and slower reflex, air
breathing smells tonsil, the vomit also smells
• By the death, cyanosis more real and arise twitch muscles
and convulsions with urinary incontinence and alvi

19. •Inhalation: palpitations, difficulty to breath, nausea, vomiting,
headache, salvasi,lakrimasi, mouth and throat irritation, dizziness
and weakness of extremities arise quickly and then collapse,
convulsions, coma and death
• Chronic poisoning victim looks pale, cold sweats, dizziness,
discomfort in the stomach, nausea and colic, feel pressed on
the chest and shortness of breath.
• Signs the end:
coma and dilated pupils, tremors, arrhythmias, convulsions, com
a emphasis on the respiratory center, respiratory failure until the
heart stop beating
• color skin looks "cherry-red"

20. Test
Paper filter test
Reaksi Schonbein – Pagenstecher ( Reaksi Guajacol)
Prussian Blue reaction
Micro Method Gittler & Golabaum

21. Therapy
• Poisoned by CN inhalation:
->move victim to the place where clean air is available, give-
amyl nitrite
with inhalation, 1 ampoule (0.2 ml) every5 minutes, stop giv
ing when the systolic blood pressure is less than 80 mmHg
-> give artificial respiration with 100% oxygen
->Antidotum in the form of sodium nitrite 3% IV
-> vary the dose
of sodium nitrite and sodium thiosulfate with Hb

22. CN poisoning ingested
• do an emergency action with inhalation of amyl nitrite, one
ampoule (0.2 ml, within 3minutes) every 5 minutes
• Give artificial respiration with 100% oxygen.
• Besides nitrite, methylene blue 1% 50 mL IV can be used
as antidotum

23. Forensic Medical Examination
cases of deaths due to poisoning:
• Examination at the place of incident
• Outdoor examination
- smell
- Clothes
- Bruises corpse
- Changes in skin color
- Nails
- Hair
- sclera

24. Body Surgery
Open chest and abdominal cavity, specify whether there is an
unusual smell (smell of poison)
• Consider the color of blood and the color of organs
is brown
reddish
• In lung, there is an acute damming

25. Material Sampling for Toxicology
Examination
Taking blood from the heart separately from the
right and left respectively for about 50 ml
• Blood side for about 30-50 ml, taken from of iliac vein
• Urine and gastric washings all of taken from the bladder
• Organ liver should be taken after reserved for pathology
anatomy examination

26. • Kidneys should be taken both
• Brain, lipoid system inside
• another way to take samples:
Get the place where toxic gets in (stomach, the injection site)
Blood
Out point (urine, bile)

27. Pemeriksaan Kedokteran Forensik
Keracunan Sianida
• pemeriksaan bagian luar jenazah  tercium bau amandel
• Sianosis pada wajah dan bibir, busa keluar dari mulut, dan
lebam mayat berwarna terang
• pemeriksaan bedah jenazah  tercium bau amandel yang
khas pada waktu membuka rongga dada, perut dan otak serta
lambung, darah, otot dan penampang tubuh dapat berwarna
merah terang

28. Examination of the exterior of the body wafted of tonsils
Cyanosis of the face and lips foam out of the mouth and
bruised corpse light colored
Surgical examination of the corpse  wafted of the spesific
tonsils distinctive when opening the chest cavity stomach,
brain and also blood, muscle, and body sections color seems
red bright

29. Medikolegal Aspects
KUHP :
Article 205
Article 359
Article 360
KUHAP
Article 133

30. Law Number 8 Year 1999 About Consumer
Protection:
Article 19
Article 60
Law Number 7 Year 1996 About Food: Article 21
Government Regulation Number 28 Year 2004
About Safety, Quality and Nutritional Food : Article 25

31. CASE
Six People is being poisoned by Cyanide Acid in
Tiwul (a food from cassava flour)
( Tue, January 18 2011 )
TEMPO Interaktif, Jepara - Substance Acid
cyanide (HCN) became the major cause the death of six
victims, children of J (45) by SJ (40):
L (24), AA (3), AK (5), MH (13) , F (15) and
SK (8) residents of Desa
Jebol, District Mayong, Jepara, Central Java, where HCN
poisoning their food named tiwul(food from cassava flour)

32. Leaf and
Cassava
Tuber
Be poisoned
Case Discussion

33. Closing
Toxicology can be defined as
a substance that can cause bad effect when it gets into a living
body, either accidentally or with intent.
• One type of poisoning that occurs is cyanide poisoning, because
the cyanide salt in a small dose is
enough to cause death in someone quickly like a suicide.
• Poisoning can through parenteral administration, inhalation, ingestio
n or skin absorption (dermal).
• Signs and symptoms depend on the mechanism,
source and quantity of cyanide that gets into the body.

34. • Forensic through the post-mortem examination and toxicology
tests can prove the existence of cyanide in the
body, or any changes and abnormalities consistent with cyanide
poisoning.
• Aspect medikolegal about cyanide poisoning regulated in KUH
P articles 205, 359, 360; KUHAP 133, Law No. 8 of
1999 about consumer protection Article 19 and 60.

35. Bibiliography
 Budiyanto A, Widiatmaka W, Sudiono S,et al. Ilmu Kedokteran Forensik. Jakarta : Bagian
Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia. 1997, hlm 71-72
 Ernest H. A Textbook of Modern Toxicology Third Edition. New Jersey : A John Wiley &
Sons, Inc, 2004, hlm 3-8
 Budiyanto A, Widiatmaka W, Sudiono S, et al. Ilmu Kedokteran Forensik, 1997.
Jakarta : Bagian Kedokteran Forensik Universitas Indonesia ; 95 – 100.
 Leybell I, Borron SW. Cyanide Toxicity. June 2nd
2010. Cited from :
http://emedicine.medscape.com/article/814287
 Budiyanto A, Widiatmaka W, Sudiono S, et al. Ilmu Kedokteran Forensik, 1997.
Jakarta : Bagian Kedokteran Forensik Universitas Indonesia ; 73 – 86
 Kitab Undang-undang Hukum Pidana
 Kitab Undang-undang Hukum Acara Pidana
 Undang-undang Nomor 8 tahun 1999 Tentang Perlindungan Konsumen
 Undang-undang Nomor 7 tahun 1996 Tentang Pangan
 Centers for Disease Control and Prevention. The Facts About Cyanides. New York
State Department Of Health. New York. 2004. Available from:
www.health.state.ny.us/nysdoh/bt/chemical_terrorism/docs/cyanide_general.pdf.
Access on: November 29, 2006
 http://gresnews.com/ch/Regional/cl/hisyam-alie/id/1810889/Enam-Tewas-
Keracunan-Asam-Sianida-Pada-Tiwul