Diagnosis and treatment of cyanide toxicity

A novel coumarin derivative-modified cellulose fluorescent probe for selective and sensitive detection of CN- in food samples

In this work, a novel coumarin derivative-modified cellulose acetate (DCB-CA) was synthesized as a fluorescent probe for highly selective and sensitive determination of CN^- in food samples. The DCB-CA was synthesized by using CA as a skeleton, and the coumarin derivative as the fluorophore. The DCB-CA obtained was characterized by different methods including FTIR, SEM, ¹H-NMR, TGA and UV-vis spectroscopy. The DCB-CA exhibited a significant "turn-off" fluorescence response to CN^-, accompanied by a distinct fluorescence color change from bright yellow to colorless. The detection limit of CN^- using DCB-CA was calculated to be 5.8 × 10^-7 M, which was much lower than the threshold limit of CN^- recommended by the World Health Organization (1.9 × 10^-6 M). Because of the favorable solubility and processability of the CA, the DCB-CA was easily processed into different fluorescent materials including fluorescent films and coatings. The fluorescent film obtained was also applied to the selective detection of CN^-. Furthermore, the DCB-CA was successfully applied to determine CN^- in food samples.

Quantitatively analysis and detection of CN- in three food samples by a novel nopinone-based fluorescent probe

Cyanide (CN^-) is one of the most lethal chemical substance and exists in the organisms and environment. Due to the CN^- and CN^--containing chemicals being widely applied in industrial fields and threatening human health, the sensitive and selective detection techniques towards CN^- are still essential. Based on this, a "turn-on" fluorescent probe 2-(4-(5,5-dimethyl-4,5,6,7-tetrahydro-3H-4,6-methanobenzo[d]imidazol-2-yl)styryl)-3-ethylbenzo[d]thiazol-3-ium iodide (NCy) was designed and synthesized for monitoring CN^-. NCy had a distinguishable color change towards CN^- from colorless to yellow under 365 nm UV-light. NCy possessed the merits including low LOD (75 nM), good selectivity, and wide suitable pH range (4-10). The sensing mechanism of NCy towards CN^- was proved by HRMS, ¹H NMR titration and DFT analysis. Furthermore, the probe NCy was successfully utilized in detecting endogenous CN^- in three food samples (green potato, cassava, and bitter almond) quantitatively. In bioimaging aspect, NCy was also successfully applied in detecting the exogenous CN^- in living zebrafish.

Colorimetric and turn-on fluorescent chemosensor with large stokes shift for sensitively probing cyanide anion in real samples and living systems

Cyanide anion is a ubiquitous chemical substance in the ecosystem, however, human daily life is severely threatened by its toxicity at any time. In this paper, a novel colorimetric and turn-on chemosensor 4-(4-(2,2-difluoro-6-methyl-2H-1,3,2-dioxaborinin-4-yl)buta-1,3-dien-1-yl)-N,N-dimethylaniline (NBF) for detecting cyanide anion was synthesized based on the 4-(dimethylamino)cinnamaldehyde and β-diketone difluoroboron complex. This fluorescent probe exhibited excellent spectroscopy properties such as large stokes shift, long emission wavelength, and good sensitivity. The detection limit of NBF towards cyanide ion was determined as low as 2.23 μM. Additionally, the detection mechanism towards cyanide ion was confirmed to be the nucleophilic addition interaction by high resolution mass spectrum (HRMS), ¹H Nuclear Magnetic Resonance (NMR) titration, and quantum chemistry theory calculation. In addition, the probe NBF had been successfully utilized in detecting cyanide ions in water and food samples as well as imaging in the biological system, which broadened its practical application prospects.

Development and Application of Multidimensional Lipid Libraries to Investigate Lipidomic Dysregulation Related to Smoke Inhalation Injury Severity

The implication of lipid dysregulation in diseases, toxic exposure outcomes, and inflammation has brought great interest to lipidomic studies. However, lipids have proven to be analytically challenging due to their highly isomeric nature and vast concentration ranges in biological matrices. Therefore, multidimensional techniques such as those integrating liquid chromatography, ion mobility spectrometry, collision-induced dissociation, and mass spectrometry (LC-IMS-CID-MS) have been implemented to separate lipid isomers as well as provide structural information and increased identification confidence. These data sets are however extremely large and complex, resulting in challenges for data processing and annotation. Here, we have overcome these challenges by developing sample-specific multidimensional lipid libraries using the freely available software Skyline. Specifically, the human plasma library developed for this work contains over 500 unique lipids and is combined with adapted Skyline functions such as indexed retention time (iRT) for retention time prediction and IMS drift time filtering for enhanced selectivity. For comparison with other studies, this database was used to annotate LC-IMS-CID-MS data from a NIST SRM 1950 extract. The same workflow was then utilized to assess plasma and bronchoalveolar lavage fluid (BALF) samples from patients with varying degrees of smoke inhalation injury to identify lipid-based patient prognostic and diagnostic markers.

Cost impact of hydroxocobalamin in the treatment of patients with known or suspected cyanide poisoning due to smoke inhalation from closed-space fires

BACKGROUND & OBJECTIVES

Cyanide poisoning can occur due to exposure to smoke in closed-space fires. With no point of care cyanide test at the scene of a fire, first responders and clinicians base decisions to treat with cyanide antidote on patient history, clinical signs, and other indirect data points that have not been proven to correspond with actual systemic levels of cyanide. The aim of this exploratory study was to determine the economic implications of treating patients with known or suspected cyanide poisoning due to smoke inhalation with hydroxocobalamin.

METHODS

A decision analysis model was developed from the US hospital perspective. Healthcare resource utilization was estimated from a retrospective evaluation of clinical outcomes in hydroxocobalamin-treated patients and in historical controls without hydroxocobalamin use (Nguyen, et al. 2017). Epidemiologic parameters and costs were estimated from the published literature, and publicly-available hospital charges were identified. Outcomes reported in the analysis included expected healthcare resource utilization in the US population and per-patient costs with and without the use of hydroxocobalamin. A cost-to-charge ratio was applied so that all costs would reflect hospital costs rather than hospital charges. Deterministic sensitivity analysis was performed to identify the most influential model parameters. All costs were reported in 2017 US dollars.

RESULTS

Use of hydroxocobalamin reduces healthcare resource utilization and contributes to decreased per-patient hospital costs ($15,381 with hydroxocobalamin treatment versus $22,607 with no cyanide antidote). The most substantive cost-savings resulted from decreased hospital length of stay (i.e., intensive care unit [ICU] and non-ICU). Costs attributed to mechanical ventilation also decreased with use of hydroxocobalamin. A univariate sensitivity analysis demonstrated that the most impactful variables in the cost analysis were related to hospital length of stay (ICU followed by non-ICU stay), followed by the daily cost of ICU stay.

CONCLUSIONS

Use of hydroxocobalamin in patients with known or suspected cyanide poisoning from closed-space fire smoke inhalation may decrease hospital costs and contribute to more efficient healthcare resource utilization.

Inhalants

Toxic inhalants include various xenobiotics. Irritants cause upper and lower respiratory tract injuries. Highly water-soluble agents injure the upper respiratory tract, while low water-soluble inhalants injure the lower track. Asphyxiants are divided into simple asphyxiants and chemical asphyxiants. Simple asphyxiants displace oxygen, causing hypoxia, while chemical asphyxiants also impair the body's ability to use oxygen. Cyanide is a classic chemical asphyxiant. Treatment includes hydroxocobalamin. Electronic cigarette or vaping use-associated lung injury (EVALI) is a relatively new illness. Patients present with respiratory symptoms and gastrointestinal distress. EVALI appears to be associated with vaping cannabinoids. Treatment is supportive and may include steroids.

RETRACTED: Proof of concept efficacy study of intranasal stabilized isoamyl nitrite (SIAN) in rhesus monkeys against acute cyanide poisoning

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editors-in-Chief as the authors were unable to provide documentation of approval for the interinstitutional assurance /vertebrate animal section of the paper by the relevant authority, Public Health Service (PHS) Office of Laboratory Animal Welfare (OLAW) in the time that was provided.

Beyond the burn: Studies on the physiological effects of flamethrowers during World War II

Flamethrowers are widely considered one of warfare's most controversial weapons and are capable of inflicting gruesome physical injuries and intense psychological trauma. Despite being the last of the major combatants in World War II (WWII) to develop them, the United States military quickly became the most frequent and adept operator of portable flamethrowers. This gave the U.S. military ample opportunity to observe the effects of flamethrowers on enemy soldiers. However, while most people in modern times would consider immolation by flamethrower to be an unnecessarily painful and inhumane way to inflict casualties, immolation was, at one point during World War II (WWII), referred to as "mercy killing" by the U.S. Chemical Warfare Service (CWS). This mischaracterization arose from a series of first-hand accounts describing what were believed to be quick, painless, and unmarred deaths, as well as from a poor and incomplete understanding of flamethrower lethality. As a result, indirect mechanisms such as hypoxia and carbon monoxide poisoning were generally absent from accounts of the flamethrower's fatal effects. It was not until several years after flamethrowers were introduced to the frontlines that the CWS and National Defense Research Committee (NDRC) conducted a series of tests to better understand the physiological and toxicological effects of flamethrowers. This article examines how the initial absence of scientific data on the physiologic effects of flamethrowers led to an inaccurate understanding of their lethality, and bizarre claims that one of history's most horrific instruments of war was considered one of the more "humane" weapons on the battlefield.

Hemodialysis failure secondary to hydroxocobalamin exposure

Hydroxocobalamin is a recently approved antidote for the treatment of cyanide poisoning. The case presented involves a young patient administered empiric hydroxocobalamin due to suspected cyanide overdose. Due to the development of acute kidney injury and severe metabolic derangement, emergent hemodialysis was initiated. Unfortunately, hemodialysis was confounded by a recurrent "blood leak" alarm. This unforeseen effect was secondary to interference from hydroxocobalamin. Hydroxocobalamin causes orange/red discoloration of bodily fluids and permeates the dialysate. This leads to defraction of light in the effluent path of the blood leak detector from discolored dialysate, which can result in activation of the blood leak alarm and an inability to continue hemodialysis treatment. This case highlights several new and emerging critical concerns with this medication, including the potential consequence of delayed initiation of emergent renal replacement therapy with empiric administration, the need for increased awareness among clinicians of various disciplines, and the need for multidisciplinary communication.

Concentrations of cyanide in blood samples of corpses after smoke inhalation of varying origin

Cyanide (CN) blood concentration is hardly considered during routine when evaluating smoke gas intoxications and fire victims, although some inflammable materials release a considerable amount of hydrogen cyanide. CN can be significant for the capacity to act and can in the end even be the cause of death. Systematic data concerning the influence of different fire conditions, especially those of various inflammable materials, on the CN-blood concentration of deceased persons do not exist. This study measured the CN level in 92 blood samples of corpses. All persons concerned were found dead in connection with fires and/or smoke gases. At the same time, the carboxyhemoglobin (COHb) level was determined, and the corpses were examined to detect pharmaceutical substances, alcohol and drugs. Furthermore, we analysed autopsy findings and the investigation files to determine the inflammable materials and other circumstances of the fires. Due to the inflammable materials, the highest concentration of CN in the victims was found after enclosed-space fires (n = 45) and after motor-vehicle fires (n = 8). The CN levels in these two groups (n = 53) were in 47 % of the cases toxic and in 13 % of the cases lethal. In victims of charcoal grills (n = 17) and exhaust gases (n = 6), no or only traces of CN were found. Only one case of the self-immolations (n = 12) displayed a toxic CN level. The results show that CN can have considerable significance when evaluating action ability and cause of death with enclosed-space fires and with motor-vehicle fires.

Physical therapy performance in the rehabilitation of survivors of the Kiss nightclub tragedy: an experience report

Abstract Introduction : As a result of a fire in the Kiss nightclub that occurred in the city of Santa Maria - RS, 242 people were killed, of whom 235 died on the day of the episode, asphyxiated by the inhalation of toxic smoke. Approximately 1,000 more were injured. Objective : To report the experience of a group of physical therapists, professors at the Federal University of Santa Maria (UFSM), in the rehabilitation of survivors of the fire, victims of burns and inhalation injury. Materials and methods : Quantitative and qualitative study, in which an evaluation protocol of physical functional ability was designed to identify rehabilitation needs. Results : Two hundred seventy patients (147 men, mean age 26.72 ± 9.5 years) were examined, of which approximately 70% had some type of clinical modification or functional impairment that indicated the need for rehabilitation. The most prevalent respiratory signs and symptoms were: dry or productive cough (59.2%); abnormal respiratory pace (11.4%); fatigue (35.92%); dyspnea (17.7%); and chest pain (16.6%). Neurological symptoms such as persistent headache (88.51%), memory loss (11.4%), and paresthesia (8.1%) were also reported. Musculoskeletal injuries (14.7%) and extensive burns (8.8%) were also observed. One hundred and eighty-nine patients were referred to outpatient physical therapy and, of these, 22 still remain at the Outpatient Physical Therapy Unit of the University Hospital of (HUSM). Conclusions : Despite the vast professional experience of this group of physical therapists, the situations experienced were unique and unprecedented, both professionally and personally, and reinforced the importance of joining forces within an emergency care unit, as well as the importance of comprehensive and multi-professional outpatient monitoring.

Acute Cyanide Poisoning: Hydroxocobalamin and Sodium Thiosulfate Treatments with Two Outcomes following One Exposure Event

Cyanide is rapidly reacting and causes arrest of aerobic metabolism. The symptoms are diffuse and lethal and require high clinical suspicion. Remediation of symptoms and mortality is highly dependent on quick treatment with a cyanide antidote. Presently, there are two widely accepted antidotes: sodium thiosulfate and hydroxocobalamin. These treatments act on different components of cyanide's metabolism. Here, we present two cases resulting from the same source of cyanide poisoning and the use of both antidotes separately used with differing outcomes.

Assessing inhalation injury in the emergency room

Respiratory tract injuries caused by inhalation of smoke or chemical products are related to significant morbidity and mortality. While many strategies have been built up to manage cutaneous burn injuries, few logical diagnostic strategies for patients with inhalation injuries exist and almost all treatment is supportive. The goals of initial management are to ensure that the airway allows adequate oxygenation and ventilation and to avoid ventilator-induced lung injury and substances that may complicate subsequent care. Intubation should be considered if any of the following signs exist: respiratory distress, stridor, hypoventilation, use of accessory respiratory muscles, blistering or edema of the oropharynx, or deep burns to the face or neck. Any patients suspected to have inhalation injuries should receive a high concentration of supplemental oxygen to quickly reverse hypoxia and to displace carbon monoxide from protein binding sites. Management of carbon monoxide and cyanide exposure in smoke inhalation patients remains controversial. Absolute indications for hyperbaric oxygen therapy do not exist because there is a low correlation between carboxyhemoglobin levels and the severity of the clinical state. A cyanide antidote should be administered when cyanide poisoning is clinically suspected. Although an ideal approach for respiratory support of patients with inhalation injuries do not exist, it is important that they are supported using techniques that do not further exacerbate respiratory failure. A well-organized strategy for patients with inhalation injury is critical to reduce morbidity and mortality.

Smoke inhalation injury during enclosed-space fires: an update

In view of the tragic fire at a nightclub in the city of Santa Maria, Brazil, which culminated in the sudden death of 232 young people, we decided to review the literature regarding smoke inhalation injury caused by enclosed-space fires, which can be divided into direct thermal damage, carbon monoxide poisoning, and cyanide poisoning. Such injuries often call for immediate orotracheal intubation, either due to acute airway obstruction or due to a reduced level of consciousness. The diagnosis and the severity of the thermal injury can be determined by fiberoptic bronchoscopy. The levels of gases and gas by-products in the bloodstream should be assessed as rapidly as possible, even while still at the scene of the incident. First responders can also treat carbon monoxide poisoning, with immediate administration of oxygen at 100%, as well as cyanide poisoning, with oxygen therapy and hydroxocobalamin injection.

Pediatric cyanide poisoning by fire smoke inhalation: a European expert consensus. Toxicology Surveillance System of the Intoxications Working Group of the Spanish Society of Paediatric Emergencies

Most fire-related deaths are attributable to smoke inhalation rather than burns. The inhalation of fire smoke, which contains not only carbon monoxide but also a complex mixture of gases, seems to be the major cause of morbidity and mortality in fire victims, mainly in enclosed spaces. Cyanide gas exposure is quite common during smoke inhalation, and cyanide is present in the blood of fire victims in most cases and may play an important role in death by smoke inhalation. Cyanide poisoning may, however, be difficult to diagnose and treat. In these children, hydrogen cyanide seems to be a major source of concern, and the rapid administration of the antidote, hydroxocobalamin, may be critical for these children.European experts recently met to formulate an algorithm for prehospital and hospital management of adult patients with acute cyanide poisoning. Subsequently, a group of European pediatric experts met to evaluate and adopt that algorithm for use in the pediatric population.

Inhalation injury: epidemiology, pathology, treatment strategies

Lung injury resulting from inhalation of smoke or chemical products of combustion continues to be associated with significant morbidity and mortality. Combined with cutaneous burns, inhalation injury increases fluid resuscitation requirements, incidence of pulmonary complications and overall mortality of thermal injury. While many products and techniques have been developed to manage cutaneous thermal trauma, relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury. Several factors explain slower progress for improvement in management of patients with inhalation injury. Inhalation injury is a more complex clinical problem. Burned cutaneous tissue may be excised and replaced with skin grafts. Injured pulmonary tissue must be protected from secondary injury due to resuscitation, mechanical ventilation and infection while host repair mechanisms receive appropriate support. Many of the consequences of smoke inhalation result from an inflammatory response involving mediators whose number and role remain incompletely understood despite improved tools for processing of clinical material. Improvements in mortality from inhalation injury are mostly due to widespread improvements in critical care rather than focused interventions for smoke inhalation.

Morbidity associated with inhalation injury is produced by heat exposure and inhaled toxins. Management of toxin exposure in smoke inhalation remains controversial, particularly as related to carbon monoxide and cyanide. Hyperbaric oxygen treatment has been evaluated in multiple trials to manage neurologic sequelae of carbon monoxide exposure. Unfortunately, data to date do not support application of hyperbaric oxygen in this population outside the context of clinical trials. Cyanide is another toxin produced by combustion of natural or synthetic materials. A number of antidote strategies have been evaluated to address tissue hypoxia associated with cyanide exposure. Data from European centers supports application of specific antidotes for cyanide toxicity. Consistent international support for this therapy is lacking. Even diagnostic criteria are not consistently applied though bronchoscopy is one diagnostic and therapeutic tool. Medical strategies under investigation for specific treatment of smoke inhalation include beta-agonists, pulmonary blood flow modifiers, anticoagulants and antiinflammatory strategies. Until the value of these and other approaches is confirmed, however, the clinical approach to inhalation injury is supportive.

Review article: management of cyanide poisoning

Cyanide poisoning is uncommon, but generates interest because of the presumed utility of an antidote immediately available in those areas with a high risk of cyanide exposure. As part of its regular review of guidelines, the Australian Resuscitation Council conducted a systematic review of the human evidence for the use of various proposed cyanide antidotes, and a narrative review of the relevant pharmacological and animal studies. There have been no relevant comparative or placebo-controlled human trials. Nine case series were identified. Treatment with hydroxocobalamin was reported in a total of 361 cases. No serious adverse effects of hydroxocobalamin were reported, and many patients with otherwise presumably fatal poisoning survived. Sodium thiosulphate use was reported in two case series, similarly with no adverse effects. Treatment with a combination of sodium nitrite, amyl nitrite and sodium thiosulphate was reported in 74 patients, with results indistinguishable from those of hydroxocobalamin and sodium thiosulphate. No case series using dicobalt edetate or 4-dimethylaminophenol were identified, but successful use in single cases has been reported. Hydroxocobalamin and sodium thiosulphate differ from alternatives in having negligible adverse effects, and on the basis of current evidence are the antidotes of choice. The indications for the use of an antidote, the requirements for supportive care and a recommended approach for workplaces where there is a risk of cyanide poisoning are presented.

Update on the critical care management of severe burns

Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.

Cyanide: an unreported cause of neurological complications following smoke inhalation

Although the combustion of natural and synthetic products can yield cyanide, its toxic role in residential fires is unclear. This case concerns a woman aged over 50 years who presented comatose, pulseless and apnoeic after a domestic fire. Cardiopulmonary resuscitation and on-site administration of 2.5 g hydroxocobalamin as an antidote to cyanide resulted in a return of spontaneous circulation. On admission to the intensive care unit, the patient was treated with hyperbaric oxygen for suspected carbon monoxide poisoning. In a blood specimen collected at the scene before hydroxocobalamin administration, blood cyanide and carbon monoxide levels were 68 µmol/l and 10.9%. On admission to hospital, plasma lactate was at 4.6 mmol/l. Brain scans revealed lesions which were confirmed 2 months later, consistent with the haemorrhagic necrosis often seen after poisoning by cyanide. These data suggest that smoke inhalation in a residential fire may cause cyanide poisoning. This case provides clinical, biological, analytical and brain imaging data supporting the hypothesis of the toxic role of smoke-induced cyanide poisoning which may result in neurological sequelae.

A review of acute cyanide poisoning with a treatment update

Cyanide causes intracellular hypoxia by reversibly binding to mitochondrial cytochrome oxidase a(3). Signs and symptoms of cyanide poisoning usually occur less than 1 minute after inhalation and within a few minutes after ingestion. Early manifestations include anxiety, headache, giddiness, inability to focus the eyes, and mydriasis. As hypoxia progresses, progressively lower levels of consciousness, seizures, and coma can occur. Skin may look normal or slightly ashen, and arterial oxygen saturation may be normal. Early respiratory signs include transient rapid and deep respirations. As poisoning progresses, hemodynamic status may become unstable. The key treatment is early administration of 1 of the 2 antidotes currently available in the United States: the well-known cyanide antidote kit and hydroxocobalamin. Hydroxocobalamin detoxifies cyanide by binding with it to form the renally excreted, non-toxic cyanocobalamin. Because it binds with cyanide without forming methemoglobin, hydroxocobalamin can be used to treat patients without compromising the oxygen-carrying capacity of hemoglobin.

[Treatment of serious burns]

BACKGROUND

Treatment of patients with large burns is challenging.

MATERIAL AND METHOD

The article is based on clinical experience, and a non-systematic review in PubMed.

RESULTS

In patients with burns covering more than 10 - 15 % of the total body surface area, fluid resuscitation should be initiated early. Fluid induces edema, and facial burns may necessitate early orotracheal intubation to secure the airways. Reduced ventilation and-/or peripheral circulation due to deep burns should be managed by early escharotomy (and, more seldom, fasciotomy) at the primary hospital. Respiratory distress is most often due to vigorous fluid resuscitation, secretions, pneumonia and-/or sepsis. Fiber bronchoscopy may reveal inhalation injury and enables removal of secreted material from the airways. In the acute initial phase, hypotension is usually caused by hypovolemia. Subsequently a massive inflammatory response (SIRS) causes vasodilatation, hypotension and increased cardiac output. Wound and airway infections are common. SIRS may cause CRP levels above 100 and a body temperature of 38 - 39 degrees C, which makes it difficult to find the right time to start antibiotic treatment. Nevertheless, prophylactic use of antibiotics is not encouraged. Definitive surgery, excision and transplantation, should be performed early, preferably within the first week.

INTERPRETATION

Patients with large burns should be treated according to general principles for intensive medical care, preferably in units with special experience in treatment of burns.

[Inhalation injury--epidemiology, diagnosis and therapy]

OBJECTIVE

Inhalation injury is a vitally threatening medical syndrome, which might appear in patients with or without burn injuries. Thus, knowledge about development, diagnosis and treatment of inhalation injury should be available for each physician working in an intensive care unit.

METHODS

This review starts with the causal and formal pathogenesis of inhalation injuries. Furthermore, diagnosis and treatment in the critical care setting are presented, followed by the discussion of possible complications. Specific intoxications such as carbon monoxide are due to their importance separately discussed.

CONCLUSIONS

Inhalation injury present with an attributable excess mortality and thus worsen the prognosis of burned patients. New insights into the pathogenesis of inhalation injury, however, have led to improved therapeutic possibilities with improved outcome. Necessary prerequisites are a timely diagnosis and restrictive volume management, especially in patients with extensive burns. Prospective studies are needed to be able to answer the many emerging questions.

Lung injury and renal failure caused by potassium cyanide poisoning

Our objective is to show that cyanide poisoning presents with various symptoms, and that recognition of these symptoms is required for appropriate management of the condition. A 54-year-old man drank about 2.5 times the normal fatal dose of potassium cyanide in a suicide attempt. On arrival at hospital (day 0), the patient was restless and in a state of shock. We administered 100% oxygen and performed immediate detoxification. Ground-glass attenuation appeared on the evening of day 1 and lung injury due to cyanide was suspected. Inflammation improved slowly with the use of artificial ventilation, but anuria continued and sudden renal failure occurred on day 2. We suspected that renal failure was due to cyanide metabolites, and continuous haemodiafiltration (CHDF) was initiated. Renal function improved slowly and CHDF was discontinued on the sixth day. Symptoms of cyanide poisoning may include lung injury and renal damage, in addition to disturbance of consciousness.

Pathophysiology, management and treatment of smoke inhalation injury

Smoke inhalation injury continues to increase morbidity and mortality in burn patients in both the third world and industrialized countries. The lack of uniform criteria for the diagnosis and definition of smoke inhalation injury contributes to the fact that, despite extensive research, mortality rates have changed little in recent decades. The formation of reactive oxygen and nitrogen species, as well as the procoagulant and antifibrinolytic imbalance of alveolar homeostasis, all play a central role in the pathogenesis of smoke inhalation injury. Further hallmarks include massive airway obstruction owing to cast formation, bronchospasm, the increase in bronchial circulation and transvascular fluid flux. Therefore, anticoagulants, antioxidants and bronchodilators, especially when administered as an aerosol, represent the most promising treatment strategies. The purpose of this review article is to provide an overview of the pathophysiological changes, management and treatment options of smoke inhalation injury based on the current literature.