ACMER Cyanide Management in the Gold Industry May 2009

Emergency
g
y Management:
g
Treatment of Cyanide
Poisoning
Wesfarmers CSBP Kwinana
Dr Nell Gillett MBBS, GradDip (OHS), CIME
Onsite Medical Officer

Introduction
Cyanide is extremely toxic and
b ffatal
t l
exposure may be
Cyanide poisoning requires
immediate treatment,
Emergency diagnosis is difficult

no pathognomonic signs
laboratory confirmation is delayed by
hours/days

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Introduction
Lack of International consensus on Best
P ti G
id li
ffor ttreatment
t
t
Practice
Guidelines
Is it cyanide poisoning?

May mimic other medical conditions which

require prompt medical attention

Review of current available literature

Routes of absorption
Inhalation
Ingestion
Through the eyes and skin
Degree of symptoms depend on degree of
exposure
Solid, liquid or gaseous phases

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Cyanide Poisoning
Cyanide causes cellular hypoxia by
enzyme inactivation
inability of cells to use oxygen
Impaired function of vital organ systems

Nervous System
Cardiovascular
Respiratory

Lactic Acidosis (Metabolic)

Acute poisoning
Clinical effects determined by

Form of cyanide (gas produces the most rapid

onset of symptoms)
Mode of entry into body
The dose

Rapidly acting ie rapid onset of symptoms

after exposure

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Signs of mild poisoning

Headache
Nausea and vomiting
Metallic taste
Drowsiness
Dizziness
Anxiety
Irritation of mucous membranes
Shortness of breath

Progression of poisoning
Increasing shortness of breath
Cyanosis
Falling/ low blood pressure (hypotension)
Cardiac arrhythmias
Impaired conscious state

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Severe cyanide poisoning

Progressive coma
S i
Seizures
Cardiac arrest
Survivors of severe poisoning may suffer
permanent brain injury through
direct toxic effects of cyanide
cerebral anoxia

Medical Treatment
Rescue and first aid
Oxygen
Decontamination
Antidotes
Transfer to Medical care

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Rescue and First Aid

DR ABC
Prompt response
Raise alarm
Hazard assessment for rescuer

Appropriate PPE and or respirator to prevent

contamination to rescuer/s is of prime importance

Remove casualty from further exposure ie fresh

air

Rescue and First Aid

DR ABC
Airway-- ensure clear, coma position if
Airway
breathing spontaneously, insert airway if
unconscious
Breathing-- NO EAR, use bag and mask
Breathing
with 100% oxygen
Circulation-- check for pulse, if absent
Circulation
commence CPR

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Oxygen
100% O2 is
considered the most
useful treatment for
early cyanide
poisoning
Administered to
anyone with
suspected cyanide
exposure, regardless
of clinical condition

Decontamination
Liquid or solid cyanide exposure
Shower and wash area with soap and
copious amounts of water ensuring water
drains from casualty
Eye contaminationcontamination- irrigate with copious
water for 10 mins

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Decontamination
Ingestion- limited evidence to support
Ingestioni / ti t d charcoal
h
l
emesis/activated

especially for exposures greater than 2 hours

previously

Specialist medical decision

Bag and seal clothing to prevent further
exposure to victim or rescuer/s

Antidotes
Not as immediately critical as the
d i i t ti off effective
ff ti rescue/first
/fi t aid
id
administration
and oxygen
International difference of opinion as to
most effective agent
Out of Hospital empirical treatment VS
Specialist Medical Care

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Antidotes
Based on 3 main modes of action

Methemoglobin generators
Direct binding agents
Sulphur donors

Convert to nonnon-toxic metabolites

Human Metabolism of Cyanide

Dr Nell Gillett Medical Treatment

ACMER Cyanide Management in the Gold Industry May 2009

Methaemoglobin generators
Oxidising agent change
ferrous (2+) to ferric (3+)
i iin h
l bi
ion
haemoglobin
resulting in
methaemoglobin (MetHb)
MetHb unable to
transport oxygen
MetHb strongly binds to
cyanide
Amyl nitrite (inhaled),
sodium nitrite (IV), DMAP

Methaemoglobin Generators
Not recommended for empirical treatment
of cyanide poisoning
Relative contra
contra--indication when carbon
monoxide poisoning also suspected ie fire
(carboxyheamaglobin)
Amyl nitrite removed as treatment from
WA Resources
R
Safety
S f t Medical
M di l Bulletin
B ll ti iin
April 2008 revision
http://www.dmp.wa.gov.au/PDF/Bulletins/MS_GMP_OH_MB5_Cya
nidePoisoning.pdf

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ACMER Cyanide Management in the Gold Industry May 2009

Amyl Nitrite
Amyl Nitrite should only
patient is
be used if he p
clearly deteriorating,
despite oxygen and there
is a reasonable
confidence that cyanide is
the cause of their
symptoms
May be used by trained
personnel until IV access
is obtained

Cummings TF. The treatment of cyanide poisoning. Occupational

Med 2004; 54: 82-85.

Direct binding Agents

Based on cobalt chemistry and directly
chelate cyanide to a non
non--toxic metabolite
Hydroxocobalamin (Cyanokit),
dicobolt edetate (Kelocyanor)
Dicobolt edetate has a significant toxicity
profile and is not recommended for
empirical use

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Hydroxocobalamin CYANOKIT

Precursor Vitamin B12 that directly binds cyanide to form

Vitamin B12
First demonstrated as effective antidote in 1952
Administer 55-15 g IV over 30 mins

Hydroxocobalamin to Vit B12

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Hydroxocobalamin CYANOKIT
Human and Animal studies

Prospecti e retrospective
retrospecti e trials
Prospective,
trials, case series

69 enclosed space fire victims in Paris

1989--1994
1989

37 comatosed, 14 cardiopulmonary arrest

Survival rate 72% (50/69)
No neurological sequelae 82% (41/50)

Borron S, Magarbane B. Hydroxocobalamin for empiric treatment of smoke

inhalation-associated cyanide poisoning:results of a prospective study in the
prehospital setting. Ann Emerg Med. 2005;46:S77

Hydroxocobalamin
Side effects

Transient reddishreddish-brown discolouration of

skin, mucous membranes and urine
Transient hypertension and reflex bradycardia
without ECG changes
Headache, rash, erythema at infusion site

Uhl W, Nolting A et al. Safety of hydroxocobalamin in healthy

volunteers in a radomised, placebo-controlled study. Clin Toxicol.
2006; 44:17-28

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Sulphur donors
Major route of
detoxification is
i off cyanide
id tto
conversion
thiocyanate
detoxification in the liver
(by the mitochondrial
enzyme rhodanese)
catalyses the transfer of
sulphur to the cyanide ion
to form thiocyanate
Sodium thiosulphate

Sodium Thiosulphate
No clinical trials to
evaluate efficacy as
stand alone antidote
Data based on human
case studies or
animal models
Slower mode of
action
ti cff CYANOKIT

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Sodium Thiosulphate
No longer preferred first line empirical
tid t
antidote
May still be a useful adjunct to
hydroxocobalamin
Administered through separate IV line

12 5 g over 10
12.5
10--20 mins

International Perspective
US-sodium nitrite
USdi b lt edetate
d t t
UK-- dicobolt
UK
France--CYANOKIT
France
Germany-- DMAP
Germany
Australia--CYANOKIT/ sodium thiosulphate
Australia
Hydrogen Cyanide Symposium Florida
2003-- CYANOKIT
2003

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Prior to approaching casualty wear appropriate

PPE and assess personal danger
Check casualty, remove from source of contamination if possible and where required. Contact Control
Room by radio and advise of situation and any special services / assistance required

CN LIQUID/SOLID
Remove all clothing and
shower (20 minutes)*
Administer 02 100% as
required

HCN/GAS
Remove to fresh air
Administer 02 100%

If symptoms resolve
Transfer to medical centre for
assessment.
After hours contact Shift
Supervisor and On-call Doctor

Urine specimen at time and 24

hours later or at commencement
of next shift and refrigerate

If symptoms deteriorate
DRABC
Request Control Room
Operator to ensure medical
assistance is alerted
Continue with 02 100%

St Johns Ambulance (Code

Red), Occupational Health
Nurse and Doctor is required

If cyanide poisoning is strongly

suspected as cause,
Administer Amyl Nitrite

SiteSafe
* Bag and seal clothing including
boots and socks to avoid further
contamination
contamination.

On arrival medical team will

administer IV antidote

If not breathing, do not attempt

mouth to mouth/nose
resuscitation. Maintain
breathing with bag/mask,
Oxyport or Oxy-Viva

Transfer to hospital for

observation/evaluation

Cyanide Kit to go with patient in

ambulance to hospital and
retrieved at a later time

Commence CPR and continue

until ER or medical assistance
arrives

Note: All SCP Core Operators and Shift

Coordinators to be Senior First Aid, Oxy-Viva
and Amyl Nitrite Administration trained.

Cyanide Kit
The cyanide antidote kit should contain:
Copy of current MSDS
Copy of WA Resources Safety Medical Bulletin
No 5
Copy of CSBP cyanide exposure protocol
Amyl Nitrate
Hydroxocobalamin Cyanokit
Sodium Thiosulphate
IV giving sets, cannulas and fluids

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Arrival of Ambulance
All patients with suspected or proven
id poisoning
i
i should
h ld b
k tto
cyanide
be ttaken
hospital for evaluation and observation
Cyanide kit must go to the hospital in the
Ambulance as it has clear instructions for
medical personnel

Take Home Messages

Primum non Noce

To rescuers
? Is it cyanide poisoning

Oxygen and supportive first aid

Lack of International consensus

N d ffor more quality

Need
lit d
data
t

Hydroxocobalamin (CYANOKIT)

Dr Nell Gillett Medical Treatment

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ACMER Cyanide Management in the Gold Industry May 2009

Questions?

Dr Nell Gillett Medical Treatment

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