Hydrogen Cyanide Poisoning Workup

  • Author: Lewis S Nelson, MD, FACEP, FAACT, FACMT; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Dec 9, 2011
 

Approach Considerations

Cyanide toxicity is characterized by a normal arterial oxygen tension and an abnormally high venous oxygen tension, resulting in a decreased arteriovenous oxygen difference (A-VO2). Also characteristic are a high-anion-gap metabolic acidosis and an elevated lactate level.[4, 10] In patients clinically suspected of cyanide poisoning, a serum lactate concentration above 8 mmol/L is a sensitive marker of toxicity.[10]

Serum cyanide concentrations are generally not available in time to guide acute treatment but may be confirmatory. The preferred test is a red blood cell (RBC) cyanide concentration. With this method, mild toxicity is observed at concentrations of 0.5-1.0 μg/mL. Concentrations of 2.5 μg/mL and higher are associated with coma, seizures, and death.

Obtain carboxyhemoglobin levels to exclude carbon monoxide poisoning, especially in smoke inhalation victims. Obtain a methemoglobin level, especially in cyanotic patients and following treatment of cyanide poisoning with sodium nitrite.

On electrocardiography (ECG), nonspecific findings predominate. Sinus bradycardia, tachycardia, heart block, or myocardial ischemic patterns may be noted.

Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Lewis S Nelson, MD, FACEP, FAACT, FACMT  Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Attending Physician, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center and New York Harbor Healthcare System

Lewis S Nelson, MD, 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, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Colleen M Rivers, MD  Senior Fellow in Medical Toxicology, New York City Poison Control Center, Bellevue Hospital Center

Disclosure: Nothing to disclose.

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Andre Pennardt, MD, FACEP, FAAEM, FAWM  Clinical Associate Professor of Emergency Medicine, Medical College of Georgia; Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Departments of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center

Andre Pennardt, MD, FACEP, FAAEM, FAWM 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.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate 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, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Additional Contributors

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

References

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  11. Musshoff F, Schmidt P, Daldrup T. Cyanide fatalities: case studies of four suicides and one homicide. Am J Forensic Med Pathol. Dec 2002;23(4):315-20. [Medline].

  12. Brennan RJ, Waeckerle JF, Sharp TW. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med. Aug 1999;34(2):191-204. [Medline].

  13. Department of the Army. Blood agents (Cyanogens). In: Field Manual 8-285: Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries. 1995:VI-1-2.

  14. USAMRICD. Cyanide. In: Field Management of Chemical Casualties Handbook. 1996:37-40.

  15. USAMRICD. Cyanide. In: Medical Management of Chemical Casualties Handbook. 1999:38-58.

  16. Kirk MA, Gerace R, Kulig KW. Cyanide and methemoglobin kinetics in smoke inhalation victims treated with the cyanide antidote kit. Ann Emerg Med. Sep 1993;22(9):1413-8. [Medline].

  17. 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].

  18. Martin CO, Adams HP. Neurological aspects of biological and chemical terrorism: a review for neurologists. Arch Neurol. Jan 2003;60(1):21-5. [Medline].

 
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