Medical Aspects of Chemical Warfare (2008) - The Black Vault

Cyanide PoisoningTABLE 11-3Endogenous cyanide concentrations for smokers and nonsmokers*NonsmokersCyanidesmokersSubsample Whole Blood Erythrocytes Plasma Saliva Whole Blood Erythrocytes Plasma SalivaSize in Study (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL)n=20 1 4.4 ± 1.0 9.9 ± 6.8 7.0 ± 1.8 17.1 ±n=5 smokers; n=10 3.5 ± 2.1 6.5 ± 5.9 0.54 ± 8.9 ± 3.2 18.0 ± 5.4 0.81 ± 13.5nonsmokers 2 0.54 0.54n=10 nonsmokers 3 51.3 ± 17.3ThiocyanateWhole Blood Plasma Urine Saliva Whole Blood Plasma Urine Saliva(ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL)n=20 1 1.94 ± 1.47 31.4 ± 23.5 6.54 ± 5.34 96.0 ± 48.82-Aminothiazoline-4-carboxylic AcidWhole Blood Plasma Urine Saliva Whole Blood Plasma Urine Saliva(ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL) (ng/mL)n=19 smokers; n=21 85 ± 47 233 ± 237nonsmokers 4n=27 smokers; n=27 11.8 ± 4.7 17.2 ± 5.2nonsmokers 5*The nonsmoker averages 0.06 µg/mL of cyanide in blood, whereas the smoker averages 0.17 µg/ mL.Data sources: (1) Seto Y. False cyanide detection. Anal Chem. 2002;74:134A–141A. (2) Lundquist P, Rosling H, Sorbo B. Determination ofcyanide in whole blood, erythrocytes and plasma. Clin Chem. 1985;31:591–595. (3) Lundquist P, Sörbo B. Rapid determination of toxic cyanideconcentrations in blood. Clin Chem. 1989;35:617–619. (4) Logue BA, Kirschten NP, Petrikovics I, Moser MA, Rockwood GA, Baskin SI. Determinationof the cyanide metabolite 2-aminothiazoline-4-carboxylic acid in urine and plasma by gas chromatography-mass spectrometry. JChromatogr B Analyt Technol Biomed Life Sci. 2005;819:237–244. (5) Maserek WK, Rockwood GA, Platoff GE, Baskin SI, Logue BA. Feasibility ofusing the cyanide metabolite 2-amino-2-thiazoline-4-carboxylic acid as a retrospective marker of cyanide exposure. Toxicol Sci. 2006;abstract1918:392. (6) Clark CJ, Campbell D, Reid WH. Blood carboxyhaemoglobin and cyanide levels in fire survivors. Lancet. 1981;1:1332–1335.use by first responders. Emergency personnel have torely initially on the history and physical symptomsof the patient, rather than wait for laboratory results,recognizing that cyanide poisoning can have symptomssimilar to other poisonings. 101,110 Blood and urinesamples should be collected and analyzed as soon aspossible for confirmation or refutation. Table 11-2 is amethod list, and Table 11-3 contains baseline concentrations(neither are intended to be all-inclusive). Inaddition, some of the methods listed have not beenthoroughly examined against suggestions 1 through5 above. When testing cannot be performed immediately,procedures such as those in Exhibit 11-1 shouldbe used to collect and store samples for later analysis.CLINICAL PRESENTATION AND MANAGEMENT OF CASUALTIESPrinciples of TherapyThe effects of cyanide poisoning are those of progressivetissue hypoxia (Figure 11-2). Many cyanidecompounds exist, but this chapter deals only with thetoxicities of HCN. Additional signs and symptomsmay occur as a result of the parent compound. Forexample, cyanogen chloride also produces irritationof the eyes and mucous membranes similar to thatproduced by chlorine.Lesser degrees of poisoning are survivable even inthe absence of specific antidotal therapies. Acute, severecyanide intoxication, however, is a life-threateningemergency. It is survivable with aggressive acute care381