Cyanogen Chloride Poisoning Workup

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

Approach Considerations

Diagnostic tests and procedures will be briefly discussed in this section.

Diagnostic tests

Cyanide poisoning is characterized by a normal arterial partial pressure of oxygen (PaO2) despite symptoms of hypoxia and an abnormally high venous oxygen pressure (PO2) (decreased arteriovenous oxygen [A-VO2] difference).

Victims of cyanogen chloride (CK) exposure may develop lowered PaO2 due to irritant effects on the respiratory tract, resulting in bronchospasm or pulmonary edema or from bradypnea or apnea.

Depending on the severity of exposure, an arterial blood gas (ABG) with a mixed respiratory and metabolic acidosis may be present. Metabolic acidosis is a hallmark of significant cyanide toxicity.

A low carbon dioxide (CO2) concentration and an elevated lactate level support the diagnosis.

Cyanide levels are generally not available in time to guide acute treatment but may be confirmatory. The preferred test is a red blood cell (RBC) cyanide level.[7, 8]

Obtain carboxyhemoglobin and methemoglobin levels, especially in victims of smoke inhalation. During treatment with sodium nitrite, observing methemoglobin levels over time may help to avoid toxic methemoglobinemia.

On electrocardiograms (ECGs), shortening of the ST segment with eventual fusion of the T wave into the QRS complex has been observed.

Procedures

Depending on the severity of symptoms, endotracheal intubation may be necessary to optimize oxygen delivery and protect the airway.

Fluorescein staining and slit lamp examination of the eyes may be necessary following decontamination to assess corneal integrity.

Proceed to Treatment & Management
 
 
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.

References

  1. Baud FJ. Cyanide: critical issues in diagnosis and treatment. Hum Exp Toxicol. Mar 2007;26(3):191-201. [Medline].

  2. Schnepp R. Cyanide: sources, perceptions, and risks. J Emerg Nurs. Aug 2006;32(4 Suppl):S3-7. [Medline].

  3. Nelson L. Acute cyanide toxicity: mechanisms and manifestations. J Emerg Nurs. Aug 2006;32(4 Suppl):S8-11. [Medline].

  4. Zheng A, Dzombak DA, Luthy RG. Formation of free cyanide and cyanogen chloride from chloramination of publicly owned treatment works secondary effluent: laboratory study with model compounds. Water Environ Res. Mar-Apr 2004;76(2):113-20. [Medline].

  5. Borron SW, Baud FJ. Acute cyanide poisoning: clinical spectrum, diagnosis, and treatment. Arh Hig Rada Toksikol. Sep 1996;47(3):307-22. [Medline].

  6. Borron SW. Recognition and treatment of acute cyanide poisoning. J Emerg Nurs. Aug 2006;32(4 Suppl):S12-8. [Medline].

  7. Baud FJ, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med. Dec 19 1991;325(25):1761-6. [Medline].

  8. Shiono H, Maseda C, Akane A, Matsubara K. Rapid and sensitive quantitation of cyanide in blood and its application to fire victims. Am J Forensic Med Pathol. Mar 1991;12(1):50-3. [Medline].

  9. 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].

  10. DesLauriers CA, Burda AM, Wahl M. Hydroxocobalamin as a cyanide antidote. Am J Ther. Mar-Apr 2006;13(2):161-5. [Medline].

  11. Koschel MJ. Management of the cyanide-poisoned patient. J Emerg Nurs. Aug 2006;32(4 Suppl):S19-26. [Medline].

  12. Shepherd G, Velez LI. Role of hydroxocobalamin in acute cyanide poisoning. Ann Pharmacother. May 2008;42(5):661-9. [Medline].

  13. Cyanokit (Hydroxocobalamin) [package insert]. Napa, CA (Semoy, France): Dey LP (Merck Sante SAS); 2006. [Full Text].

  14. Litovitz TL, Larkin RF, Myers RA. Cyanide poisoning treated with hyperbaric oxygen. Am J Emerg Med. Jul 1983;1(1):94-101. [Medline].

  15. Scolnick B, Hamel D, Woolf AD. Successful treatment of life-threatening propionitrile exposure with sodium nitrite/sodium thiosulfate followed by hyperbaric oxygen. J Occup Med. Jun 1993;35(6):577-80. [Medline].

  16. Tabrah FL, Tanner R, Vega R, Batkin S. Baromedicine today--rational uses of hyperbaric oxygen therapy. Hawaii Med J. Apr 1994;53(4):112-5, 119. [Medline].

  17. Tomaszewski CA, Thom SR. Use of hyperbaric oxygen in toxicology. Emerg Med Clin North Am. May 1994;12(2):437-59. [Medline].

  18. Ivanov KP. [Effect of incresed oxygen pressure on animals poisoned by potassium cyanide.]. Farmakol Toksikol. Sep-Oct 1959;22:468-73. [Medline].

  19. Skene WG, Norman JN, Smith G. Effect of hyperbaric oxygen in cyanide poisoning. Proceedings of the Third International Congress on Hyperbaric Medicine. 1966:705-710.

  20. Takano T, Miyazaki Y, Nashimoto I, Kobayashi K. Effect of hyperbaric oxygen on cyanide intoxication: in situ changes in intracellular oxidation reduction. Undersea Biomed Res. Sep 1980;7(3):191-7. [Medline].

  21. Eckstein M. Enhancing public health preparedness for a terrorist attack involving cyanide. J Emerg Med. Jul 2008;35(1):59-65. [Medline].

  22. Fortin JL, Giocanti JP, Ruttimann M, Kowalski JJ. Prehospital administration of hydroxocobalamin for smoke inhalation-associated cyanide poisoning: 8 years of experience in the Paris Fire Brigade. Clin Toxicol (Phila). 2006;44 Suppl 1:37-44. [Medline].

  23. Geller RJ, Barthold C, Saiers JA, Hall AH. Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs. Pediatrics. Nov 2006;118(5):2146-58. [Medline].

  24. Guidotti T. Acute cyanide poisoning in prehospital care: new challenges, new tools for intervention. Prehosp Disaster Med. Mar-Apr 2006;21(2 Suppl 2):s40-8. [Medline].

  25. Hall AH, Dart R, Bogdan G. Sodium thiosulfate or hydroxocobalamin for the empiric treatment of cyanide poisoning?. Ann Emerg Med. Jun 2007;49(6):806-13. [Medline].

  26. Kerns W 2nd, Beuhler M, Tomaszewski C. Hydroxocobalamin versus thiosulfate for cyanide poisoning. Ann Emerg Med. Mar 2008;51(3):338-9. [Medline].

  27. Kindwall EP. Carbon monoxide and cyanide poisoning. In: Hyperbaric Medicine Practice. 2nd ed. Arizona: Best Publishing Company; 1995:363-372.

  28. Morocco AP. Cyanides. Crit Care Clin. Oct 2005;21(4):691-705, vi. [Medline].

  29. Schecter WP, Fry DE. The surgeon and acts of civilian terrorism: chemical agents. J Am Coll Surg. Jan 2005;200(1):128-35. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.