Etiology

Smoke inhalation, suicidal ingestion, and industrial ex-

posures are the most frequent sources of cyanide poi-
soning. Treatment with sodium nitroprusside or long-
term consumption of cyanide-containing foods is a
possible source. Historically, cyanide has been used
as a chemical warfare agent, and it could potentially
be an agent for a terrorist attack.

Smoke inhalation
Smoke inhalation during house or industrial fires is the
major source of cyanide poisoning in the United
States. Individuals with smoke inhalation from en-
closed space fires who have soot in the mouth or
nose, altered mental status, or hypotension may have
significant cyanide poisoning (blood cyanide concen-
trations > 40 mmol/L or approximately 1 mg/L).

Many compounds containing nitrogen and carbon may

produce hydrogen cyanide (HCN) gas when burned.
Some natural compounds (eg, wool, silk) produce HCN
as a combustion product. Household plastics (eg,
melamine in dishware, acrylonitrile in plastic cups),
polyurethane foam in furniture cushions, and many
other synthetic compounds may produce lethal con-
centrations of cyanide when burned under appropriate
conditions of oxygen concentration and temperature.

Intentional poisoning
Cyanide ingestion is an uncommon, but effective,
means of suicide. These cases typically involve
health-care and laboratory workers who have access
to the cyanide salts found in hospital and research lab-
oratories.

Large-scale contamination of food supplies is a poten-

tial terrorist threat and could cause mass casualties.
Unlike inhalation exposure, cyanide continues to be
absorbed following ingestion and by the time patients
present they are usually unresponsive, in respiratory
failure.

Industrial exposure
Countless industrial sources of cyanides exist.
Cyanides are used particularly in the metal trades,
mining, jewelry manufacturing, dyeing, photography,
and agriculture. Specific industrial processes involving
cyanide include metal cleaning, reclaiming, or harden-
ing; fumigation; electroplating; and photo processing.
In addition, industry uses cyanides in the manufacture
of plastics, as reactive intermediates in chemical syn-
thesis, and as solvents (in the form of nitriles).

Exposure to salts and cyanogens only occasionally

causes poisonings; however, a significant risk for mul-
tiple casualties occurs when these products come into
contact with mineral acids because HCN gas is pro-
duced. A mass casualty incident may develop in an in-
dustrial accident in which cyanogen chloride comes in
contact with water (eg, during firefighting). Containers
of cyanogen chloride may rupture or explode if ex-
posed to high heat or following prolonged storage.

Iatrogenic exposure
The vasodilator nitroprusside sodium, when used in
high doses or over a period of days, can produce toxic
blood concentrations of cyanide. Patients with low
thiosulfate reserves (eg, malnourished, postoperative)
are at increased risk for developing symptoms, even
with therapeutic dosing. Resultant confusion and com-
bativeness initially may be mistaken as intensive care
unit (ICU) syndrome (ie, sundowning). Problems may
be avoided by coadministration of hydroxocobalamin
or sodium thiosulfate.