Cyanide Toxicity Clinical Presentation

  • Author: Inna Leybell, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Nov 1, 2011
 

History

The delay between exposure and the onset of symptoms depends on the type of cyanide involved, the route of entry, and the dose. Rapidity of symptom onset, depending on the type of cyanide exposure, occurs in the following order (most rapid to least rapid): gas, soluble salt, insoluble salt, and cyanogens.

A history of recent depression in the patient with sudden collapse or altered mental status, acidosis, and tachyphylaxis in the ICU patient on nitroprusside should evoke suspicion of the diagnosis.

Symptoms may include the following:

  • General weakness, malaise, and collapse
  • Neurologic symptoms (reflecting progressive hypoxia) - Headache, vertigo, dizziness, giddiness, inebriation, confusion, generalized seizures, coma
  • Gastrointestinal symptoms - Abdominal pain, nausea, vomiting
  • Cardiopulmonary symptoms - Shortness of breath, possibly associated with chest pain, apnea
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Physical Examination

Physical findings of cyanide exposure are generally nonspecific, yet the onset of illness may be dramatic. Findings can include the following:

  • Vital signs are variable
  • Initial bradycardia and hypertension - May rapidly give way to hypotension with reflex tachycardia, with resulting final bradycardia and hypotension
  • Tachypnea - May generally precede apnea
  • High, falsely reassuring pulse oximetry - Oxygen is present in the blood as oxyhemoglobin but cannot be effectively used in oxidative phosphorylation
  • Cherry-red skin color - Reflecting absent tissue oxygen extraction
  • Soot in the mouth and nose after smoke inhalation - The possibility of cyanide poisoning is particularly suggested if altered mental status and/or hypotension are present; mydriasis and bright red retinal arteries and veins (due to absent tissue oxygen extraction) may be observed; the smell of bitter almonds on the breath suggests exposure (cannot be detected by 60% of the population)
  • Cardiopulmonary symptoms - Include possible cardiogenic pulmonary edema; aspiration can occur with coma

Neurologic symptoms may include the following:

  • Confusion, drunken behavior, ataxia
  • Mydriasis
  • Generalized convulsions
  • Coma
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Contributor Information and Disclosures
Author

Inna Leybell, MD  Clinical Assistant Professor, Department of Emergency Medicine, NYU Langone Medical Center

Inna Leybell, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Student Association/Foundation, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Stephen W Borron, MD, MS, FAAEM, FACEP, FAACT, FACMT  Professor of Emergency Medicine and Medical Toxicology, Division of Medical Toxicology, Department of Emergency Medicine, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center; Associate Medical Director, West Texas Regional Poison Center

Stephen W Borron, MD, MS, FAAEM, FACEP, FAACT, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, American Industrial Hygiene Association, and European Association of Poisons Centres and Clinical Toxicologists

Disclosure: Meridian Pharmaceuticals Consulting fee Consulting

Carlos J Roldan, MD, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Texas Health Science Center at Houston Medical School; Consulting Staff, Department of Emergency Medicine, Memorial Hermann Hospital and Lyndon Baines General Hospital

Carlos J Roldan, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Pain Society, American Society of Regional Anesthesia and Pain Medicine, International Association for the Study of Pain, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Frederic J Baud, MD Director, Professor, Toxicological and Medical Intensive Care Unit, Hôpital Lariboisiere of Paris, France

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM, Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM, is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Robert S Hoffman, MD, FAACT, FACMT Associate Professor, Departments of Emergency Medicine and Medicine, Clinical Pharmacology, New York University School of Medicine, Consulting Staff, Department of Emergency Services, Bellevue and New York University Hospital

Robert S Hoffman, MD, FAACT, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, American College of Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

References

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  4. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila). Dec 2009;47(10):911-1084. [Medline].

  5. Lee J, Mukai D, Kreuter K, et al. Potential interference by hydroxocobalamin on co-oximetry hemoglobin measurements during cyanide and smoke inhalation treatments. Ann Emerg Med. 2007;49(6):802-805. [Medline].

  6. Fortin JL, Desmettre T, Manzon C, Judic-Peureux V, Peugeot-Mortier C, Giocanti JP, et al. Cyanide poisoning and cardiac disorders: 161 cases. J Emerg Med. May 2010;38(4):467-76. [Medline].

  7. Borron SW, Baud FJ, Mégarbane B, Bismuth C. Hydroxocobalamin for severe acute cyanide poisoning by ingestion or inhalation. Am J Emerg Med. Jun 2007;25(5):551-8. [Medline].

  8. Borron SW, Baud FJ, Barriot P, Imbert M, Bismuth C. Prospective study of hydroxocobalamin for acute cyanide poisoning in smoke inhalation. Ann Emerg Med. Jun 2007;49(6):794-801, 801.e1-2. [Medline].

  9. Bebarta VS, Tanen DA, Lairet J, Dixon PS, Valtier S, Bush A. Hydroxocobalamin and sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of acute cyanide toxicity in a swine (Sus scrofa) model. Ann Emerg Med. 2010;55(4):345-51. [Medline].

  10. Curry SC, Connor DA, Raschke RA. Effect of the cyanide antidote hydroxocobalamin on commonly ordered serum chemistry studies. Ann Emerg Med. Jul 1994;24(1):65-7. [Medline].

  11. Sutter M, Tereshchenko N, Rafii R, Daubert GP. Hemodialysis Complications of Hydroxocobalamin: A Case Report. J Med Toxicol. Mar 30 2010;[Medline].

  12. Hall AH, Saiers J, Baud F. Which cyanide antidote?. Crit Rev Toxicol. 2009;39(7):541-52. [Medline].

 
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