Cyanide poisoning from metal cleaning solutions

Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs

Confirmed cases of childhood exposure to cyanide are rare despite multiple potential sources including inhalation of fire smoke, ingestion of toxic household and workplace substances, and ingestion of cyanogenic foods. Because of its infrequent occurrence, medical professionals may have difficulty recognizing cyanide poisoning, confirming its presence, and treating it in pediatric patients. The sources and manifestations of acute cyanide poisoning seem to be qualitatively similar between children and adults, but children may be more vulnerable than adults to poisoning from some sources. The only currently available antidote in the United States (the cyanide antidote kit) has been used successfully in children but has particular risks associated with its use in pediatric patients. Because hemoglobin kinetics vary with age, methemoglobinemia associated with nitrite-based antidotes may be excessive at standard adult dosing in children. A cyanide antidote with a better risk/benefit ratio than the current agent available in the United States is desirable. The vitamin B12 precursor hydroxocobalamin, which has been used in Europe, may prove to be an attractive alternative to the cyanide antidote kit for pediatric patients. In this article we review the available data on the sources, manifestations, and treatment of acute cyanide poisoning in children and discuss unmet needs in the management of pediatric cyanide poisoning.

Lethal cyanide inhalation with post-mortem trans-cutaneous cyanide diffusion

A 27-year-old worker in a metal processing factory was found dead in a basin, sitting in a solution containing potassium dicyano argentate, potassium cyanide, master batch and brightener 'Elfit 73'. The worker was wearing an acid-resisting overall, rubber boots and a simple dust respirator. While the cyanide concentration in the stomach contents was only 0.05 microg/ml, it was 7.7 microg/g in the lung tissue, 6.3 microg/ml in the heart blood and 31 microg/ml in the femoral vein blood. The different concentrations suggest an initial lethal inhalation of cyanide and an extensive post-mortem diffusion of cyanide through primarily non-injured skin of buttocks and legs. The possibility of a post-mortem cyanide diffusion bars from concluding a vital sign from a high cyanide concentration in a blood sample of one single body site.

An incident of hydrogen cyanide poisoning

Seven cases of hydrogen cyanide gas poisoning which occurred in an industrial building in Hong Kong are presented here. Two of them were more severely injured and required specific antidotal treatment. The other five were mild and responded to supportive treatment alone. All except one patient recovered completely. Cyanide poisoning is relatively uncommon in urbanized area, so high index of suspicion is important for early diagnosis and treatment. We believe that prevention of cyanide poisoning can be achieved by proper storage of chemicals, and by enforcing rescuers to wear special chemical protective clothing to avoid systemic poisoning because of dermal absorption of hydrogen cyanide gas. As there are newer and safer cyanide antidotes available, each emergency department should have a stock of updated products such as hydroxocobalamin.

The clinical experience of acute cyanide poisoning

The authors reviewed the clinical manifestations, complications, and the prognosis affected by Lilly Cyanide Antidote in 21 victims of acute cyanide poisoning over a 10-year period. The clinical signs and symptoms in cyanide poisoning are variable. Among 21 cases, loss of consciousness (15), metabolic acidosis (14), and cardiopulmonary failure (9) were the three leading manifestations of cyanide intoxication. Anoxic encephalopathy (6) was not uncommon in the severely intoxicated victims. Diabetes insipidus (1) or clinical signs and symptoms mimicking diabetes insipidus (3) may be an ominous sign to encephalopathy victims. The major cause of fatal cyanide poisoning is the intentional ingestion of cyanide compounds as part of a suicide attempt. Decrease of arteriovenous difference of O2 partial pressure may be a clue for the suspicion of cyanide intoxication. Although the authors cannot show a statistically significant difference (P = .47) for the Lilly cyanide antidote kit in terms of improving the survival rate for victims of cyanide poisoning, the antidote kit was always mandatory in our study in the cases of severely intoxicated victims who survived. Early diagnosis, prompt, intensive therapy with antidote, and supportive care are still the golden rules for the treatment of acute cyanide poisoning, whether in the ED or on the scene.

Poisonings in laboratory personnel and health care professionals

A case report of an unresponsive chemist presenting to the emergency department is presented; in retrospect, the patient was discovered to have intentionally ingested cyanide. A review of literature regarding ingestions in laboratory and health care personnel reveals five common points encountered in these personnel: barbiturates, carbon monoxide, cyanide, azides, and methemoglobin-inducing chemicals. Key diagnostic findings, in the absence of history of exposure, are discussed for these five agents.