Treatment of acute cyanide intoxication with hemodialysis

Cyanide toxicity secondary to apricot (Prunus armeniaca) kernel meal ingestion in a canine

Cyanide is one of the most rapidly acting, lethal poisons in human and veterinary medicine. This case report discusses a novel case of cyanide toxicity from apricot (Prunus armeniaca) kernel ingestion in a canine and alternative treatment modalities. A 9.5-year-old female spayed Golden Retriever presented for vomiting and collapse after ingestion of apricot kernel meal. Laboratory findings, including a high anion gap metabolic acidosis with severe hyperlactatemia, clinical signs, and known ingestion of apricot kernels, were suggestive of cyanide toxicity. The dog was treated with crystalloid and synthetic colloids for stabilization and antidote therapy with hydroxocobalamin. The dog's metabolic acidosis and hyperlactemia worsened despite antidote therapy, and the dog progressed to CPA during gastric decontamination efforts. The dog did not respond to CPR efforts. This report will review the mechanism of cyanide toxicity, treatment options, and considerations for future cases.

Role of Hemodialysis in the Management of Cyanide Intoxication From Apricot Kernels in a 3-Year-Old Child

Cyanide (CN) is one among the most potent and rapidly acting lethal poisons, and it may cause death unless immediately diagnosed and treated. We report an unusual case of pediatric CN poisoning after ingestion of apricot kernels containing amygdalin, who survived with antidotal therapy and hemodialysis. A 3-year-old girl presented with respiratory distress and coma following tonic-clonic convulsions after ingestion of 3 apricot kernels. She had severe metabolic acidosis (pH 6.91, bicarbonate [HCO3] 5.6 mEq/L, base excess -26.0 mEq/L). Her blood CN level was measured 3.15 mg/L, 3 hours after ingestion. Hydroxocobalamin could not be administered immediately because it had to be brought from a medical center 4 hours apart. Therefore, a 3-hour hemodialysis session was carried out, following which she showed some clinical improvement. In addition, when hydroxocobalamin was obtained, it was then administered. During follow-up, she was completely asymptomatic with blood pressure, and other hemodynamic parameters normalized. This case presents hemodialysis as a way to correct metabolic derangements from CN poisoning and suggests that it may have a role in select cases of pediatric CN poisoning, especially when CN-scavenging antidotes may be unavailable.

Treatment of Cyanide and Thiocyanate Toxicity Secondary to Sodium Nitroprusside

Objective:

To provide the reader with an update on the disposition of nitroprusside in the body and the current therapy in managing cyanide and thiocyanate toxicity.

Data Sources:

Currently available literature reports were used to provide readers with a comprehensive framework that will enable them to monitor for, prevent, and if needed, treat patients with cyanide and/or thiocyanate toxicity. Additional sources were used to provide risk factors, which enable practitioners to identify patients predisposed to such toxicities while receiving nitroprusside.

Conclusions:

The continuously changing climate in healthcare and the added visibility of pharmacologic agents in the treatment and prevention of disease have increased pressure on pharmacy departments to provide therapeutic agents that are cost-effective and at the same time result in minimal adverse reactions. Members of the healthcare professions must be able to identify situations that warrant close therapeutic monitoring to prevent extended hospital stays caused by iatrogenic diseases. Nitroprusside is a frequently used agent that can result in extended hospital stays, increased resource use, and even death caused by cyanide and/or thiocyanate toxicity. The identification of patients at risk, methods to monitor therapy, and treatments for toxicity will help reduce such reactions and provide maximal therapeutic response with minimal toxic consequences when using nitroprusside.

Haemodiafiltration for Poisoning with an Unknown Substance

We describe the case of a young male, found collapsed following poisoning with an unknown substance. He had a Glasgow Coma Score (GCS) of three with a profound metabolic acidosis, despite poisoning with a substance which was strongly basic. He was treated with haemodiafiltration to correct the biochemical derangements. The poison was found to be cyanide, so the patient was also given sodium thiosulphate as an antidote. We review the pathophysiology of cyanide toxicity, the antidotes available and discuss the role of haemodiafiltration in poisoning where the ingested substance is unknown.

Dialysis for Thiocyanate Intoxication: A Case Report and Review of the Literature

Limited data are available on the use of dialysis to treat cyanide or thiocyanate intoxication. This report describes the case of a 65-year-old woman with renal insufficiency who had development of thiocyanate toxicity secondary to a nitroprusside infusion. A rapid decline in her blood thiocyanate level was observed in response to initiation of continuous venovenous hemodiafiltration.

Cyanides

Cyanide is a likely weapon for terrorists due to its notoriety, lethality, and availability. Poisoning results in central nervous system and cardiovascular dysfunction due to inhibition of oxidative phosphorylation. Laboratory findings of anion gap metabolic acidosis and hyperlactemia aid in confirming the diagnosis. Treatment for significant poisonings includes aggressive supportive care and administration of antidotes such as sodium nitrite, sodium thiosulfate, and hydroxocobalamin. Survivors of significant poisonings can have long-term neurologic dysfunction.

Cyanide poisoning and its treatment

Cyanide is both widely available and easily accessible throughout the world. Although the compound is not frequently encountered, it has been used as a poison and contaminant in the past and is a potential terrorist agent. Cyanide has the ability to cause significant social disruption and demands special attention to public health preparedness. It can be obtained from a variety of sources, including industrial, medical, and even common household products. Another frequently encountered source of cyanide exposure is residential fires. Exposure to high concentrations of the chemical can result in death within seconds to minutes. Long-term effects from cyanide exposure can cause significant morbidity. The only treatment for cyanide toxicity approved for use in the United States is a kit consisting of amyl nitrite, sodium nitrite, and sodium thiosulfate. Future research aims to find a faster-acting, more effective, and better tolerated treatment for cyanide toxicity.

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.

[Potassium cyanide poisoning treated with hydroxocobalamin]

A fifteen-year-old girl, with a clean medical history, was admitted to the intensive care unit 90 minutes after ingestion of 2.5 g potassium cyanide. She had typical signs of severe cyanide poisoning including deep coma, circulatory failure, and major metabolic acidosis. Gastric lavage and antidotal treatment with 4 g hydroxocobalamin and 8 g sodium hyposulfite was administered without delay together with supportive treatment consisting of mechanical ventilation with FIO2, blood alkalinisation and administration of beta-stimulants. These measures led to a rapid clinical improvement. The ventilatory support was discontinued after 24 hours and the patient left the intensive care unit on the fourth day with only slightly impaired mental status. She survived despite a very high blood cyanide concentration (494 mumol.l-1 on admission) probably because of the rapid symptomatic and antidotal treatment.

Cyanide poisoning from metal cleaning solutions

We report two cases of cyanide poisoning from accidental ingestion of an imported metal cleaning solution used by some Southeast Asians for shining coins. Both patients received specific therapy and recovered completely after a dramatic sequence of sudden collapse and severe cardiovascular compromise.