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Smoke Inhalation and the Possibility of Cyanide Poisoning
When managing
patients subjected to smoke inhalation, the physician's attention is often
focused on looking for and treating burns, hypoxia and carbon monoxide.
Clinicians should also be aware of the possibility of cyanide poisoning.
During combustion of nitrogen-containing natural and synthetic products
(wool, silk, plastics) large amounts of cyanide can be produced.
Rapid diagnosis and treatment of cyanide toxicity can be challenging.
Not only is making the diagnosis often difficult, administering treatment
routinely can be detrimental. The sodium nitrite component of the Lilly
Cyanide Antidote Kit results in the production of methemoglobin which
will enhance the toxicity of an already high concentration of COHb.
Consider the following when treating a patient with signs and symptoms
of smoke inhalation:
1. Recognizing that there is a high correlation of cyanide poisoning when serum lactate levels are greater than 10 mmol/L;
2. If the patient is critically
ill (coma, seizures, cardiac dysrhythmias, acidemia, hypotension)
all findings suggestive of cyanide poisoning, consider giving the patient
the 12.5 g dose of sodium thiosulfate from the cyanide kit, which has
no risk of enhancing toxicity. If the patient remains unstable, particularly
if the lactate level is above 10 mmol/L and the patient's status cannot
be explained by other causes (for example, the COHb level is low) then
consider carefully administering the rest of the antidote kit.
Simultaneous toxicity from both carbon monoxide and cyanide has been
widely reported and appears to be a major contributor to the mortality
associated with smoke inhalation.
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