Cyanogen Chloride Poisoning Treatment & Management

  • Author: Heather Murphy-Lavoie, MD, FAAEM; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Nov 17, 2011
 

Prehospital and Emergency Department Care

Prehospital management of the patient with cyanogen chloride (CK) poisoning includes the following:

  • Remove the victim from the cyanide source; rescuers must have the highest level of respiratory protection (level A) (see also CBRNE - Personal Protective Equipment and HAZMAT)
  • Prioritize decontamination of the eyes with water; remove contaminated clothing, and decontaminate the skin as appropriate with soap and water
  • Aggressively administer oxygenation, manage airway control, and provide supportive care with intravenous (IV) access and continuous cardiac monitoring
  • Administer antidotes, if available, as soon as possible in suspected or known cases of cyanide toxicity

In the emergency department, continuation of hemodynamic support and optimization of oxygenation are the mainstays of treatment. The following management is also included:

  • If not performed at the scene, decontaminate patients by removing and isolating clothing and washing the patient from head to toe with soap and water; avoid self-contamination of hospital workers.
  • Following ocular decontamination, check for corneal integrity
  • Initiate antidote therapy with hydroxocobalamin, or nitrites and sodium thiosulfate, as soon as possible (see Medications)[9, 10, 11, 12] ; do not delay treatment for confirmatory red blood cell (RBC) cyanide levels
  • Aggressive management of seizure activity with benzodiazepines is crucial
  • Consider gastric lavage and administration of charcoal in cases of recent cyanide ingestion; the gastric aspirate may cause secondary contamination and must be treated as hazardous.

Transfer

Should patients require transfer to a facility with the appropriate level of care, hemodynamically stabilize them before transfer. Transfer with an advanced cardiac life support (ACLS) level of service under continuous cardiac monitoring with supplemental oxygen and intravenous access. Assure cyanide antidote availability before transfer.

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Hospitalization

Patients with symptoms of cyanide toxicity beyond minor upper airway irritation and those with abnormal blood gases require admission to the hospital for continued monitoring and support.

Perform continuous cardiac monitoring, and optimize oxygenation, as well as monitor serum lactate levels and arterial and venous blood gases. In addition, monitor for delayed onset of pulmonary edema in those presenting with evidence of respiratory irritation.

Consultations

Consult with law enforcement authorities and the Federal Bureau of Investigation (FBI) in any suspected terrorist incident.

Consultation with a medical toxicologist and/or poison control center and intensivist may be useful.

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Long-Term Monitoring and Prognosis

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

Patients treated with hydroxocobalamin who develop skin erythema should be cautioned to avoid exposure to sunlight while the discoloration persists due to possible photosensitivity. These patients may also develop red discoloration of their urine as an expected side effect that resolves without treatment.

The prognosis in patients with cyanogen chloride (CK) poisoning is better in those with low-level exposures whose symptoms resolve after they are removed from exposure. However, the prognosis is generally poor in patients who suffer cardiac arrest secondary to cyanide toxicity, even if antidotes are administered promptly.

Parkinsonlike syndromes and other neuropsychiatric sequelae have been described in survivors of severe cyanide intoxication.

In high concentrations, which can be obtained in enclosed spaces, cyanogen chloride (CK) is a rapidly acting lethal agent that causes death within 6-8 minutes.

For patient education information, see Cyanide Poisoning, Chemical Warfare, Personal Protective Equipment, and Carbon Monoxide Poisoning.

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Contributor Information and Disclosures
Author

Heather Murphy-Lavoie, MD, FAAEM  Assistant Professor, Assistant Residency Director, Emergency Medicine Residency, Associate Program Director, Hyperbaric Medicine Fellowship, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine

Heather Murphy-Lavoie, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jorge A Martinez, MD, JD  Clinical Professor, Department of Internal Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane School of Medicine

Jorge A Martinez, MD, JD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Cardiology, American College of Emergency Physicians, American College of Physicians, and Louisiana State Medical Society

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.

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Chemical Terrorism Agents and Syndromes. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/chemical.html.
 
 
 
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