- Dear Dr.
-
- The Texas Department of Public Health issued the following
alert this morning:
-
- A truck containing 10 tons of sodium cyanide was recently
stolen near Mexico City, Mexico. The truck has been recovered, but 83
of the 96 containers, each carrying 100 kilograms of sodium cyanide each,
are missing. The FBI has no evidence that the chemical is destined for
Texas or that it will be used for terrorism. However, it is important
that health care providers and facilities be prepared to diagnosis, treat,
and report patients presenting with symptoms of cyanide poisoning.
-
- If you suspect cyanide poisoning in any individual, you
should:
-
- 1. Treat the patient supportively; for specific information
about antidotes call the Texas Poison Center Network, 24 hrs a day at 1-800-222-1222.
-
- 2. Call your local law enforcement office or the FBI.
Cyanide compounds kill by preventing delivery of oxygen to organs. Cyanide
could be deployed as a gas or in a water-soluble form through the water
or food supply.
-
- The delay between exposure and onset of symptoms depends
on the compound, route of exposure, and dose. Cyanide gas is the most rapid
in onset - with symptoms occurring within fifteen seconds of exposure.
Without intervention, death occurs within ten minutes of exposure to a
high concentration of cyanide gas. Ingested soluble salts of cyanide have
the second fastest onset, followed by ingested insoluble salts, and then
by ingested cyanogens.
-
- Signs and Symptoms: Shortly after exposure the patient
may experience flushing, shortness of breath, palpitations, chest pain,
headache, dizziness, nausea, and confusion. With significant poisoning
the patient becomes stuporous, combative, and then experiences convulsions
and apnea. The taste or scent of bitter almonds is sometimes noted. The
skin may be bright pink to cherry red. Venous blood may be the same color
as arterial blood. Early tachycardia and hypertension may be followed
by bradycardia and hypotension.
-
- Differential Diagnosis: encephalitis; stroke; uremia;
diabetic ketoacidosis; or exposure to paraldehyde/phenformin, iron/isoniazid,
lactate, ethylene glycol, salicylates, carbon monoxide, hemlock, strychnine,
or sodium azide.
-
- Diagnostic Tests: Draw arterial and venous blood gases,
serum electrolytes, and plasma lactate. Metabolic acidosis combined with
an arterial-venous oxygen saturation difference of less than 10mm Hg suggests
cyanide poisoning. If lactic acidosis is not present, exposure to cyanide
has NOT occurred. Pulse oximetry is not reliable in diagnosing cyanide
poisoning.
-
- Supportive laboratory tests: The ECG may show tachycardia
or bradycardia, sinoventricular tachycardia, atrioventricular block, ventricular
arrhythmias, and ischemic changes followed by asystole. ST segment depression,
and shortening of the ST segment with eventual fusion of the T wave into
the QRS complex have been reported.
-
- Treatment: Keep the patient warm and quiet. Administer
high-flow 100% oxygen. Intubate immediately if the patient is unconscious
or the airway endangered. Establish an IV line. Monitor cardiac function.
After donning protective gear, remove all contaminated clothing and wash
the skin with plenty of water. Wash contaminated eyes for at least ten
minutes. DO NOT give mouth to mouth or mouth to nose resuscitation.
-
- For information regarding antidotes call poison control
at 1-800-222-1222.
-
- Contamination Control: Emergency and other medical personnel
must use appropriate personal protective equipment to protect themselves
from secondary exposure.
-
- Report: Immediately report any suspect cases to the local
health authority at 800-705-8868 or the Texas Department of Health at 800-252-8239;
reports may also be faxed to (512) 458-7616.
-
- Please check http://www.thd.state.tx.us for information
updates.
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- Sincerely,
-
- Fred Merian, MD President Texas Medical Association
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