Under which clinical scenarios should cyanide poisoning be suspected?.The patient went into cardiac arrest shortly after arrival to the emergency department and subsequently expired despite receiving appropriate antidotal therapy and aggressive resuscitative measures. Urine immunoassay drug of abuse screen was negative.įurther history obtained from the mother revealed that the pill bottle found with the patient contained laetrile which she had been taking to prevent cancer. Ethanol, acetaminophen, and salicylate concentrations were undetectable. Transaminases and other measures of liver function were normal. Initial plasma lactate 17.3 mmol/L (normal range 0 - 2.2 mmol/L). Measured serum osmolarity was 302 mOsm/kg and calculations yielded an osmol gap of 2 (normal range -5 to 15). Serum chemistry was significant for bicarbonate 7 mEq/L, glucose 226 mg/dL and an anion gap of 34. Blood was obtained for analysis immediately following intubation and an arterial blood gas revealed: pH 6.97, pCO2 37 mmHg, and pO2 235 mmHg. Electrocardiogram demonstrated sinus tachycardia but was otherwise normal. The physician decided to intubate the patient to protect his airway. There was no evidence of trauma, and his pupils were equal and reactive to light and bedside glucose test was 231 mg/dL. On examination he was unconscious but did withdraw to painful stimuli in all extremities. His initial vital signs were temperature 36.9 degrees Celsius rectally, blood pressure 72/48 mmHg, heart rate 150 beats/minute, RR 26 breaths/minute, and oxygen saturation 100% on facemask with oxygen flow rate of 15 liters/min. Accidental occupational or environmental exposure as well as intentional poisoning are possible, and rapid recognition and treatment with the appropriate antidote is essential to prevent mortality.Ī 6 year old male with a past medical history of autism presents to the Emergency Department after being found by his parents unresponsive next to an open bottle of pills. It is also found naturally within certain pitted fruits and is a by-product of combustion. Cyanide is widely used across multiple industries including metallurgy, photography, plastic manufacturing, fumigation, jewelry polishing, cosmetics, and chemical synthesis. Updated February, 2023 by Jeremy Hardin, MD and Binh Ly, MDĪcute cyanide poisoning is rare and often life-threatening if untreated.
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