eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Cyanides, Hydrogen: Follow-up

Author: Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Coauthor(s): Andre Pennardt, MD, FACEP, FAAEM, Adjunct Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center
Contributor Information and Disclosures

Updated: Mar 11, 2008

Follow-up

Further Inpatient Care

  • Admit patients who present with more than minimal symptoms that resolve without treatment for observation and supportive care. Also, a 24-hour observation period is necessary for those exposed to nitriles, since delayed onset of toxicity is expected.
  • Optimize oxygenation and provide continuous cardiac monitoring.
  • Monitor serum lactate levels, chemistries, and arterial and/or venous blood gases.

Further Outpatient Care

  • Reevaluate patients for neurologic sequelae 7-10 days after discharge from the hospital.

Inpatient & Outpatient Medications

  • No additional medications beyond initial antidotes are indicated. Continue to administer oxygen as required.

Transfer

  • If a patient requires transfer to a higher-level medical facility, the transferring physician should ensure availability of an ACLS emergency medical service unit that can provide continuous cardiac and hemodynamic monitoring and oxygen therapy as well as the availability of cyanide antidotes.

Complications

  • Parkinsonian symptoms and other neuropsychiatric sequelae are described in survivors of severe cyanide poisoning, resulting from damage to the basal ganglia and other areas sensitive to injury. The prevalence is unknown, but patients should be given close neurologic follow-up care.

Prognosis

  • Prognosis is good for patients who have only minor symptoms that do not require administration of antidotes.
  • Prognosis is poor once cardiovascular collapse occurs in severe cyanide poisoning. These victims are considered expectant in a mass casualty setting.
  • Prognosis is fair for patients with seizures or recent-onset apnea if antidotes can be administered rapidly. These victims are triaged "immediate" in a mass casualty setting.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider diagnosis of cyanide toxicity, thereby delaying administration of antidotes
  • Failure to recognize concomitant carbon monoxide poisoning
  • Failure to admit a patient exposed to nitriles (acetonitrile or propionitrile)
 


More on CBRNE - Cyanides, Hydrogen

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Differential Diagnoses & Workup: CBRNE - Cyanides, Hydrogen
Treatment & Medication: CBRNE - Cyanides, Hydrogen
Follow-up: CBRNE - Cyanides, Hydrogen
Multimedia: CBRNE - Cyanides, Hydrogen
References
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References

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  4. 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].

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Further Reading

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Keywords

cyanides, AC, hydrocyanic acid, HCN, cyanide, chemical warfare agent, chemical weapon, cyanide exposure, hydrogen cyanide exposure, cyanogen chloride, cyanide poisoning, hydrogen cyanide poisoning, hydrogen cyanide exposure, terrorism

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Contributor Information and Disclosures

Author

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Andre Pennardt, MD, FACEP, FAAEM, Adjunct Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center
Andre Pennardt, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US, International Society for Mountain Medicine, National Association of EMS Physicians, Special Operations Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Suzanne White, MD, Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine
Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP, Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Director, Center for Disaster and Humanitarian Assistance Medicine
Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

 
 
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