Management of Cyanide Poisoning

The treatment of patients with cyanide poisoning requires fast and precise diagnosis, in addition,
prompt clinical decisions are needed to reduce the risk of morbidity and mortality in patients. The level
of patient risk is strongly influenced by the dose and duration of exposure to cyanide in the patient. In
principle, therapeutic management of cyanide poisoning can follow these steps:

a. Decontamination
Decontamination according to the path of exposure, can generally be categorized as
follows:
1) Inhalation: move patient to a location free from exposure fumes and remove patient
clothing.
2) Eyes and skin: take off contaminated clothing, wash exposed skin with soap and / or water,
irrigate eyes exposed to water or saline, remove contact lenses.
3) Gastrointestinal tract: do not induce emesis, activated charcoal can be given if the patient is
conscious and within 1 hour of cyanide exposure. Emesis isolates can be given to aid in the
excretion of hydrogen cyanide.

b. Basic life support (BLS) / Advanced Cardiac Life Support (ACLS).

According to the American Hearth Association Guidelines in 2005, this BLS procedure
can be abbreviated as the ABC technique, namely airway (freeing the airway), breathing (giving
artificial breath), and circulation (massage the heart in shock conditions). However, in 2010 the
BLS action was changed to CAB (circulation, breathing, airway). The main purpose of BLS is to
protect the brain from irreversible damage from hypoxia, because blood circulation will stop for
3-4 minutes.
In cases of cyanide poisoning where utilization has decreased, administering 100%
oxygen to the patient with a nonrebreather mask or endotracheal tube may be helpful. This can
help the effectiveness of the use of antidotes by competing with cyanide to the binding site of
the cytochrome oxidase.

c. Antidote therapy
One of the keys to the success of cyanide poisoning therapy is the use of antidotes as
soon as possible with empirical experience without having to know the patient's detailed health
condition in advance. In America, there are two antidotes that have been approved by the FDA,
namely cyanide antidote kits that have been used for decades and hydroxocobalamin which
were approved in 2006. The cyanide antidote kit is a combination of 3 types of antidotes that
work synergistically (amyl nitrite, sodium nitrite, and sodium thiosulfate ). In the following table
it can be seen the difference in the mechanism of action and the dosage for the use of the two
types of antidotes.
1) Amyl nitrite
It can only produce about 5% methemoglobin and is not sufficient for use as a
single therapy. Amyl nitrite doses that can increase methemoglobin production are often
associated with hypotension. In fact, amyl nitrite has been phased out in the United States
due to the unpredictable build-up of methemoglobin and associated vasodilation which
can lead to hypotension. amyl nitrate can also cause vasodilation, which can reverse the
initial effects of cyanide
2) Sodium nitrite.
It is the drug most commonly used for cyanide poisoning. The standard starting
dose is 3% 10 ml sodium nitrite solution, taking approximately 12 minutes to form
approximately 40% methemoglobin. The starting dose for sodium thiosulfate is 50 ml.
The use of sodium nitrate is not without risks because if it is excessive it can result in
methemoglobinemia which can cause hypoxia or hypotension, for that, the amount of
methemoglobin must be controlled. The use of sodium nitrite is not recommended for
patients who have a deficiency of glucose-6-phosphate dehydrogenase (G6DP) in their
red blood cells because it can cause serious hemolysis reactions..
Nitrite causes methemoglobin with cyanide to form the nontoxic substance
cyanmethemoglobin. Methemoglobin does not have a higher affinity for cyanide than
cytochrome oxidase, but is more likely to cause methemoglobin than cytochrome
oxidase. Side effects of nitrite use include methemoglobin formation, vasodilation,
hypotension, and tachycardia. Preventing rapid formation, monitoring blood pressure,
and administering the correct dosage will reduce the occurrence of side effects.
3) Sodium thiosulfate
Sodium thiosulfate is a sulfur donor that converts cyanide into a more nontoxic
form, thiocyanate, with the sulfurtransferase enzyme, rhodanase. Thiocyanates are
nontoxic compounds, and can be administered empirically in cyanide poisoning.
Research with test animals has shown a better antidote when combined with
hydroxocobalamin. Sodium thiosulfate is also useful for preventing the accumulation of
cyanide in patients receiving long-term nitroprusside infusion..
4) Hydroxycobalamin
 Hydroxycobalamin is a precursor of cyanocobalamin (vitamin B12). The use of
hydroxycobalamin as a precaution in long-term administration of sodium nitroprusside
has been equally effective in the treatment of acute cyanide poisoning for more than 40
years. This compound reacts directly with cyanide and does not react with hemoglobin to
form methemoglobin.
Hydroxocobalamin itself outside the United States has been used for more than
30 years because it is safer to use in pregnant patients, who have a history of
hypotension, and patients who are exposed to cyanide through the inhalation route. In
addition, side effects are relatively smaller and easier to apply for prehospitalization
conditions. The following is data on the risk of side effects and considerations for
choosing an antidote in cases of cyanide poisoning.
d. Supporting therapy
Supporting therapy that can be done in patients is by:
1) Monitor the patient's cardiovascular, respiratory and cardiovascular functions in the ICU
2) Perform laboratory tests to monitor arterial blood gas levels, serum lactate levels,
complete blood tests, blood sugar levels, blood cyanide levels and electrolyte levels.
3) Monitoring and arrhythmia therapy.
4) Monitoring and therapy for side effects of using antidotes.

Referensi

Baskin,S.I., Kelly, J.B., Mallner, B.I., Rockwood, G., Zoltani, C., Chapter 11. Cyanide Poisoning. In Medical
Aspects of Chemical Warfare.371-410

Beasley, D.M.G., Glass, W. I., 1998. Cyanide poisoning: pathophysiology and treatment
recommendations. Occup. Med, 48:427-431

Henry, J.A., Wiseman, 1997, Management of Poisoning : A handbook for health care workers, World
Health Organization, Geneva

Jillian, H., 2011, A Review of Acute Cyanide Poisoning With a Treatment Update. Critical Care Nurse,
31(1): 72-81

Meredith, T.J., 1993, Antidots For Poisoning by Cyanide.