Cyanide Intoxication

Medical Faculty of
Trisakti University
Jakarta
Background
Many substances that may cause someone
experiencing a poisoned until it brings a death.
Substances that active chemically and physiology in
one body, at the point of certain dose (toxic) will bring
an unhealthiness or may cause a death.
Forensic discuss about toxic substance from its varies,
symptoms caused, and method forensic examination to
handle either for alive or dead victims.
Scope of Matters
Toxicology definition and factors that affect toxicity
Epidemiology, signs and symptoms, pharmacokinetic,
laboratory examination, and treatment/therapy of
cyanide poisoning
Forensic examination of patient that experiencing
common poison and cyanide poison
medikolegal aspects of deliberate poisoning or
unintentionally
Example case of cyanide poisoning 
Toxicology Definition
As a part of medical science that focused on toxic
Study about nature and mechanism of toxic effect,
varies substance towards living things and other
biologic system
A study about source, characteristic and a savor from
toxic, indication and treatment against poisoning and
other abnormality found in dead victim
Toxic Definition

A substance that may cause bad effect when it gets

into a body of a living things, either intentionally or
unintentionally
Toxic
Origin:
Plants (opium, cocaine, curare, aflatoxin)
Animals (poison/snake toxin, spider/marine animals)
Mineral (arsenic, plumbum, and things that made from
synthetic)
Heroin
Toxic
Venue:
Nature-free (poison gas in nature, household)
Poison agriculture (insecticides, herbesida, pesticides)
Toxic industrial laboratories and industry
(acid and strong base, heavy metals)
Toxic food(CN in cassava, botulinus toxic,
preservative, additives substance and toxic in the form
of medicine e.g. sedative hypnotic)
Toxic
Organs that affected:
• Hepatotosik
• Nephrotoxic
Work mechanism:
• Toxic that bind sulfhydryl group (Pb)
• Effect on ATP-ase
• Forming methemoglobin (nitrate and nitrite)
The effects:
• Local
• Systemic
• local-systemic
 Exposure to toxic substances on humans and
living things:
regular consumption
exposure from work
environmental exposure and poisoning, either
intentionally or unintentionally
Factors that affect poisoning:
How to enter:
Age
Body condition
Habits
Idiosinkrasi and allergic to vitamin E, penicilin,
streptomycin dan procaine
Time delivery
Cyanide
A deadly toxic substance
• Effects are very fast and can cause death within a
few minutes
• Hydrogen cyanide (formonitrile)
• In the form of liquid ->
 prussit acid and hydrocyanic acid
• Liquids can also be colorless or pale blue at  the
temperature of normal room
• volatile and flammable
• diffuse either by air and explosives
• Very easy to mix with water
• Otherforms: sodium cyanide and potassium cyanide
 (powder and white)
Epidemiology
• a major contributor
to morbidity and mortality, observed in approximately 5,00
0 to10,000 deaths occur from inhaling fog each year in
the united states
•  Exposure suicide rarely reported to poison centers and
18 of 242 (in 2007) and 25 of238 (in 2008) cases
of cyanide poisoning is deliberate exposure as reported to
the American Association of Poison Control Centers
•  fatal suicide in adult patients may easily be
associated with sudden death from
myocardial infarction, pulmonary embolism, or ventricular 
dysrhythmias
Source
Low-dose in nature and in every product that we
usually eat or use
Cyanide can be produced by bacteria, fungi and algae
Cyanide is found in cigarettes, motor vehicle
fumes, and food and the synthetic product
Cyanide in seed plants,especially grains (cassava wild, 
wild tubers, Intersection buffoonery,
 wild cherry, plum, apricot, wild amigdalin, 
jetberry bush, etc.)
Exposures
Fog Inhalation
Intentional poisoning (suicide)
Industry exposure
Iatrogenic exposure
Consumption of Supplements Containing Cyanide
 (Uncommon)
Pharmacokinetic
 Cyanide in the
body will inactive some oxidative enzymes radically the whole
system, especially cytochrome oxidase by binding
to the ferric heme group from the oxygen carried by blood
 The process of oxidation and reduction occurs as follows:

 Cytochrome oxidase Fe + + Fe + + + cytochrome oxidase
+
                                              CN
                        /---- Fe + + + cytochrome oxidase-cyanide-

Oxidize cyanide d in the body get into

cyanates and sulfosianat and expelled from the body through urine. 
Toxic dose orally for HCN is 60-90 mg, while doses toxic to KCN or
NaCN is 200 mg.
 Signs and Symptoms
 Main effects: hypoxia system arise progressively
Symptoms and physical signs that found are depend on the
• The dose of cyanide
• Number of exposures
• Type of exposure
• Types of cyanide component

 symptoms in the body:
• blood pressure, vision, lung, central nerve,  heart,  endocrine system,
autonomic system and metabolic system
• sore eyes because of irritation and difficulty breathing due to irritate
the respiratory tract mucosa
• high concentrations only within 15 seconds hiperpnea, 15 seconds to
lose consciousness. 3 minutes of apnea is a period of 5-
8 minutes will cause the heart muscle activity is hampered due
to hypoxia and ends with death
• Exposure of hydrogen cyanide 
may cause irritation against eyes  and skin immediately after
exposure or at least 30 to 60 minutes
In low concentrations, the effects of cyanide emerging about
15-30 minutes later
 Early signs of cyanide poisoning:
• Temporary hiperpnea
• Headache
• dyspnea
• Anxiety
• Changes in behavior such as agitation and restlessness
• Sweating a
lot, reddish skin color, body feels weak and vertigo
• cyanosis of the face, the foam out from the mouth,
 rapid and weak pulse, rapid breathing
and sometimes irregular, dilated pupils and slower reflex, 
air breathing smells tonsil, the vomit also smells 
• By the death,  cyanosis more real
 and arise twitch muscles  and convulsions  with urinary
incontinence and alvi
•Inhalation: palpitations, difficulty to
breath, nausea, vomiting,
headache, salvasi,lakrimasi, mouth and throat irritation, dizzin
ess and weakness of extremities  arise quickly  and then 
collapse,  convulsions,  coma and death
• Chronic poisoning victim looks pale, cold sweats, dizziness,
discomfort in the stomach, nausea and colic, feel pressed on
the chest and shortness of breath.
• Signs the end: 
coma and dilated pupils, tremors, arrhythmias, convulsions, c
oma emphasis on the
respiratory center, respiratory failure until the heart stop
beating
• color skin looks "cherry-red"
 Test
Paper filter test
Reaksi Schonbein – Pagenstecher ( Reaksi Guajacol)
Prussian Blue reaction
Micro Method Gittler & Golabaum
Therapy
• Poisoned by CN inhalation:
->move victim to the place where clean air is
available, give-amyl nitrite
with inhalation, 1 ampoule (0.2 ml) every5 minutes, st
op giving when the systolic blood pressure is less than
80 mmHg
-> give artificial respiration with 100% oxygen
->Antidotum in the form of sodium nitrite 3% IV
-> vary the dose
of sodium nitrite and sodium thiosulfate with Hb
CN poisoning ingested
• do an emergency action with inhalation of amyl nitrite,
 one  ampoule (0.2 ml, within 3minutes) every 5 minutes
• Give artificial respiration with 100% oxygen.
• Besides nitrite,   methylene blue 1% 50 mL IV can be
used as antidotum
Forensic Medical Examination
cases of deaths due to poisoning:
• Examination at the place of incident
• Outdoor examination
- smell
- Clothes
- Bruises corpse
- Changes in skin color
- Nails
- Hair
- sclera
Body Surgery
Open
chest and abdominal cavity, specify whether there is an
unusual smell (smell of poison)
• Consider the color of blood and the color of organs
is brown
reddish
• In lung, there is an acute damming
Material Sampling for Toxicology
Examination
Taking blood from the heart separately from the
right and left respectively for about 50 ml
• Blood side for about 30-50 ml, taken
from of iliac vein
• Urine and gastric washings all of taken from
the bladder
• Organ liver should be taken after reserved
for pathology anatomy examination
• Kidneys should be taken both
• Brain, lipoid system inside
• another way to take samples:
Get the place where toxic gets in (stomach, the injection
site)
Blood
Out point (urine, bile)
Pemeriksaan Kedokteran Forensik
Keracunan Sianida
• pemeriksaan bagian luar jenazah  tercium bau
amandel
• Sianosis pada wajah dan bibir, busa keluar dari mulut,
dan lebam mayat berwarna terang
• pemeriksaan bedah jenazah  tercium bau amandel
yang khas pada waktu membuka rongga dada, perut
dan otak serta lambung, darah, otot dan penampang
tubuh dapat berwarna merah terang
Examination of the exterior of the body wafted of
tonsils
Cyanosis of the face and lips foam out of the mouth
and bruised corpse light colored
Surgical examination of the corpse  wafted of the
spesific tonsils distinctive when opening the chest
cavity stomach, brain and also blood, muscle, and
body sections color seems red bright
Medikolegal Aspects
KUHP :
Article 205
Article 359
Article 360

KUHAP
Article 133
Law Number 8 Year 1999 About Consumer
Protection:
Article 19
Article 60
Law Number 7 Year 1996 About Food: Article 21
Government Regulation Number 28 Year 2004
About Safety, Quality and Nutritional Food : Article
25
 CASE

Six People is being poisoned by Cyanide Acid in

Tiwul (a food from cassava flour)
( Tue, January 18 2011 )
TEMPO Interaktif, Jepara - Substance Acid
cyanide (HCN) became the major cause the death
of six victims, children of  J (45) by SJ (40):
 L (24), AA (3), AK (5), MH (13) , F (15) and
SK (8) residents of Desa
Jebol, District Mayong, Jepara, Central Java, where H
CN poisoning their food named
tiwul(food from cassava flour)
 Case
Discussion

Leaf and Be poisoned

Cassava
Tuber
 Closing
 Toxicology can be defined as
a substance that can cause bad effect when it gets into a living
body, either accidentally or with intent.
• One type
of poisoning that occurs is cyanide poisoning, because
the cyanide salt in a small dose is
enough to cause death in someone quickly like a suicide.
• Poisoning can through parenteral administration, inhalation, i
ngestion or skin absorption (dermal).
• Signs and symptoms depend on the mechanism,
source and quantity of cyanide that gets into the body.
• Forensic through the post-
mortem examination and toxicology tests can prove the
existence of cyanide in the
body, or any changes and abnormalities consistent with
cyanide poisoning.
• Aspect medikolegal about cyanide poisoning regulated i
n KUHP articles 205, 359, 360; KUHAP 133, Law
No. 8 of 1999 about consumer protection
Article 19 and 60.
Bibiliography
 
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Jakarta : Bagian Kedokteran Forensik Fakultas Kedokteran Universitas
Indonesia. 1997, hlm 71-72
 Ernest H. A Textbook of Modern Toxicology Third Edition. New Jersey : A
John Wiley & Sons, Inc, 2004, hlm 3-8
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1997. Jakarta : Bagian Kedokteran Forensik Universitas Indonesia ; 95 –
100.
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http://emedicine.medscape.com/article/814287
 Budiyanto A, Widiatmaka W, Sudiono S, et al. Ilmu Kedokteran Forensik,
1997. Jakarta : Bagian Kedokteran Forensik Universitas Indonesia ; 73 – 86
 Kitab Undang-undang Hukum Pidana
 Kitab Undang-undang Hukum Acara Pidana
 Undang-undang Nomor 8 tahun 1999 Tentang Perlindungan Konsumen
 Undang-undang Nomor 7 tahun 1996 Tentang Pangan
 Centers for Disease Control and Prevention. The Facts About Cyanides. New
York State Department Of Health. New York. 2004. Available from:
www.health.state.ny.us/nysdoh/bt/chemical_terrorism/docs/cyanide_general.pd
f. Access on: November 29, 2006
 http://gresnews.com/ch/Regional/cl/hisyam-alie/id/1810889/Enam-Tewas-
Keracunan-Asam-Sianida-Pada-Tiwul