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Case Files of the University of Massachusetts Toxicology Fellowship: Does This Smoke Inhalation Victim Require Treatment with Cyanide Antidote?

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Abstract

Cyanide toxicity is common after significant smoke inhalation. Two cases are presented that provide framework for the discussion of epidemiology, pathogenesis, presenting signs and symptoms, and treatment options of inhalational cyanide poisoning. An evidence-based algorithm is proposed that utilizes point-of-care testing to help physicians identify patients who benefit most from antidotal therapy.

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References

  1. Residential and nonresidential building fire estimates. FEMA, Emmitsburg, MD 21727. 2014. http://www.usfa.fema.gov/statistics/estimates/index.shtm. Accessed 9/18 2013.

  2. Einhorn IN. Physiological and toxicological aspects of smoke produced during the combustion of polymeric materials. Environ Health Perspect. 1975;11:163–89.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Grabowska T, Skowronek R, Nowicka J, Sybirska H. Prevalence of hydrogen cyanide and carboxyhaemoglobin in victims of smoke inhalation during enclosed-space fires: a combined toxicological risk. Clin Toxicol (Phila). 2012;50(8):759–63.

    Article  CAS  Google Scholar 

  4. Borron SW. Recognition and treatment of acute cyanide poisoning. J Emerg Nurs. 2006;32(4 Suppl):S12–8.

    Article  PubMed  Google Scholar 

  5. Anseeuw K, Delvau N, Burillo-Putze G, De Iaco F, Geldner G, Holmstrom P, et al. Cyanide poisoning by fire smoke inhalation: a European expert consensus. Eur J Emerg Med. 2013;20(1):2–9.

    Article  PubMed  Google Scholar 

  6. Persson SA, Cassel G, Sellstrom A. Acute cyanide intoxication and central transmitter systems. Fundam Appl Toxicol. 1985;5(6 Pt 2):S150–9.

    Article  CAS  PubMed  Google Scholar 

  7. Nelson L. Goldfrank’s toxicologic emergencies. 9th ed. New York: McGraw Hill; 2010.

    Google Scholar 

  8. Moore SJ, Ho IK, Hume AS. Severe hypoxia produced by concomitant intoxication with sublethal doses of carbon monoxide and cyanide. Toxicol Appl Pharmacol. 1991;109(3):412–20.

    Article  CAS  PubMed  Google Scholar 

  9. Norris JC, Moore SJ, Hume AS. Synergistic lethality induced by the combination of carbon monoxide and cyanide. Toxicology. 1986;40(2):121–9.

    Article  CAS  PubMed  Google Scholar 

  10. O'Brien DJ, Walsh DW, Terriff CM, Hall AH. Empiric management of cyanide toxicity associated with smoke inhalation. Prehosp Disaster Med. 2011;26(5):374–82.

    Article  PubMed  Google Scholar 

  11. Department of Health. Use of antidotes in cyanide poisoning. 2009. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/browsable/DH_4875689 Accessed 9/23 2013.

  12. Eckstein M, Maniscalco PM. Focus on smoke inhalation—the most common cause of acute cyanide poisoning. Prehosp Disaster Med. 2006;21(2):s49–55.

    PubMed  Google Scholar 

  13. Baud FJ, Barriot P, Toffis V, Riou B, Vicaut E, Lecarpentier Y, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med. 1991;325(25):1761–6.

    Article  CAS  PubMed  Google Scholar 

  14. Borron SW, Baud FJ, Barriot P, Imbert M, Bismuth C. Prospective study of hydroxocobalamin for acute cyanide poisoning in smoke inhalation. Ann Emerg Med. 2007;49(6):794–801. e1-2.

    Article  PubMed  Google Scholar 

  15. Renard C, Borron SW, Renaudeau C, Baud FJ. Sodium thiosulfate for acute cyanide poisoning: study in a rat model. Ann Pharm Fr. 2005;63(2):154–61.

    Article  CAS  PubMed  Google Scholar 

  16. Baud F. Efficacy and safety of antidotes for acute poisoning by cyanides. Brussels, Belgium2013. Report No.: Technical Report No. 121.

  17. Fortin JL, Ruttiman M, Domanski L, Kowalski JJ. Hydroxocobalamin: treatment for smoke inhalation-associated cyanide poisoning. Meeting the needs of fire victims. Jems. 2004;29(suppl):18–21.

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  19. Kerns 2nd W, Beuhler M, Tomaszewski C. Hydroxocobalamin versus thiosulfate for cyanide poisoning. Ann Emerg Med. 2008;51(3):338–9.

    Article  PubMed  Google Scholar 

  20. Streitz MJ, Bebarta VS, Borys DJ, Morgan DL. Patterns of cyanide antidote use since regulatory approval of hydroxocobalamin in the United States. Am J Ther. 2014;21(4):244–9.

    PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  22. Hall AH, Kulig KW, Rumack BH. Suspected cyanide poisoning in smoke inhalation: complications of sodium nitrite therapy. J Toxicol Clin Exp. 1989;9(1):3–9.

    CAS  PubMed  Google Scholar 

  23. Modin A, Bjorne H, Herulf M, Alving K, Weitzberg E, Lundberg JO. Nitrite-derived nitric oxide: a possible mediator of ‘acidic-metabolic’ vasodilation. Acta Physiol Scand. 2001;171(1):9–16.

    CAS  PubMed  Google Scholar 

  24. Geldner G, Koch EM, Gottwald-Hostalek U, Baud F, Burillo G, Fauville JP, et al. Report on a study of fires with smoke gas development: determination of blood cyanide levels, clinical signs and laboratory values in victims. Anaesthesist. 2013;62(8):609–16.

    Article  CAS  PubMed  Google Scholar 

  25. Yen D, Tsai J, Wang LM, Kao WF, Hu SC, Lee CH, et al. The clinical experience of acute cyanide poisoning. Am J Emerg Med. 1995;13(5):524–8.

    Article  CAS  PubMed  Google Scholar 

  26. Baud FJ. Cyanide: critical issues in diagnosis and treatment. Hum Exp Toxicol. 2007;26(3):191–201.

    Article  CAS  PubMed  Google Scholar 

  27. 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.

    Article  CAS  Google Scholar 

  28. Baud FJ, Borron SW, Megarbane B, Trout H, Lapostolle F, Vicaut E, et al. Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning. Crit Care Med. 2002;30(9):2044–50.

    Article  CAS  PubMed  Google Scholar 

  29. Fortin JL, Desmettre T, Manzon C, Judic-Peureux V, Peugeot-Mortier C, Giocanti JP, et al. Cyanide poisoning and cardiac disorders: 161 cases. J Emerg Med. 2010;38(4):467–76.

    Article  PubMed  Google Scholar 

  30. O'Brien B, Quigg C, Leong T. Severe cyanide toxicity from ‘vitamin supplements’. Eur J Emerg Med. 2005;12(5):257–8.

    Article  PubMed  Google Scholar 

  31. Johnson RP, Mellors JW. Arteriolization of venous blood gases: a clue to the diagnosis of cyanide poisoning. J Emerg Med. 1988;6(5):401–4.

    Article  CAS  PubMed  Google Scholar 

  32. Peddy SB, Rigby MR, Shaffner DH. Acute cyanide poisoning. Pediatr Crit Care Med. 2006;7(1):79–82.

    Article  PubMed  Google Scholar 

  33. Martin-Bermudez R, Maestre-Romero A, Goni-Belzunegui MV, Bautista-Lorite A, Arenas-Cabrera C. Venous blood arteriolization and multiple organ failure after cyanide poisoning. Intensive Care Med. 1997;23(12):1286.

    Article  CAS  PubMed  Google Scholar 

  34. Yeh MM, Becker CE, Arieff AI. Is measurement of venous oxygen saturation useful in the diagnosis of cyanide poisoning? Am J Med. 1992;93(5):582–3.

    Article  CAS  PubMed  Google Scholar 

  35. Baud FJ. Acute poisoning with carbon monoxide (CO) and cyanide (CN). Ther Umsch. 2009;66(5):387–97.

    Article  PubMed  Google Scholar 

  36. Benaissa ML, Megarbane B, Borron SW, Baud FJ. Is elevated plasma lactate a useful marker in the evaluation of pure carbon monoxide poisoning? Intensive Care Med. 2003;29(8):1372–5.

    Article  PubMed  Google Scholar 

  37. Megarbane B, Delahaye A, Goldgran-Toledano D, Baud FJ. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003;66(4):193–203.

    PubMed  Google Scholar 

  38. Baud FJ, Borron SW, Bavoux E, Astier A, Hoffman JR. Relation between plasma lactate and blood cyanide concentrations in acute cyanide poisoning. Bmj. 1996;312(7022):26–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Yeoh MJ, Braitberg G. Carbon monoxide and cyanide poisoning in fire related deaths in Victoria. Australia J Toxicol Clin Toxicol. 2004;42(6):855–63.

    Article  CAS  PubMed  Google Scholar 

  40. Pfizer. Cyanokit product insert. http://www.cyanokit.com/pdf/CYANOKIT_Perscribing_Information_5-06-2011.pdf. Accessed 9/28 2013.

  41. Bebarta VS, Tanen DA, Lairet J, Dixon PS, Valtier S, Bush A. Hydroxocobalamin and sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of acute cyanide toxicity in a swine (Sus scrofa) model. Ann Emerg Med. 2010;55(4):345–51.

    Article  PubMed  Google Scholar 

  42. Avila J, Prasad D, Weisberg LS, Kasama R. Pseudo-blood leak? A hemodialysis mystery. Clin Nephrol. 2013;79(4):323–5.

    Article  PubMed  Google Scholar 

  43. Longo LD. The biological effects of carbon monoxide on the pregnant woman, fetus, and newborn infant. Am J Obstet Gynecol. 1977;129(1):69–103.

    Article  CAS  PubMed  Google Scholar 

  44. Murphy PJ. The fetal circulation. Contin Educ Anaesth Crit Care Pain. 2005;5(4):107–12.

    Article  Google Scholar 

  45. Curry SC, Carlton MW, Raschke RA. Prevention of fetal and maternal cyanide toxicity from nitroprusside with coinfusion of sodium thiosulfate in gravid ewes. Anesth Analg. 1997;84(5):1121–6.

    CAS  PubMed  Google Scholar 

  46. Graeme KA, Curry SC, Bikin DS, Lo Vecchio FA, Brandon TA. The lack of transplacental movement of the cyanide antidote thiosulfate in gravid ewes. Anesth Analg. 1999;89(6):1448–52.

    CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. University of Massachusetts, 55 Lake Ave North, Worcester, MA, 01605, USA

    Eike Hamad

  2. Department of Emergency Medicine, University of Massachusetts, 55 Lake Ave North, Worcester, MA, 01605, USA

    Kavita Babu

  3. Department of Emergency Medicine and Medical Toxicology, University of Colorado School of Medicine, Aurora, CO, USA

    Vikhyat S. Bebarta

  4. Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO, USA

    Vikhyat S. Bebarta

  5. CBRNE Enhanced Response Force Package (CERFP), Colorado Air National Guard, Buckley AFB, Aurora, CO, USA

    Vikhyat S. Bebarta

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  1. Eike Hamad
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  2. Kavita Babu
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  3. Vikhyat S. Bebarta
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Correspondence to Eike Hamad.

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Hamad, E., Babu, K. & Bebarta, V.S. Case Files of the University of Massachusetts Toxicology Fellowship: Does This Smoke Inhalation Victim Require Treatment with Cyanide Antidote?. J. Med. Toxicol. 12, 192–198 (2016). https://doi.org/10.1007/s13181-016-0533-0

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  • DOI: https://doi.org/10.1007/s13181-016-0533-0

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