The Unknown Exposure

A brief occupational history may provide a clue to the diagnosis of cyanide poisoning in an acutely ill adult. In patients with work-related industrial poisoning, the diagnosis is suggested by the patient's occupation and circumstances. Often, multiple exposures result from the same incident. Suicidal ingestions of cyanide often occur in patients whose occupations provide access to cyanide salts. These include industrial and research chemists, laboratory technicians, science students, and jewelers. A history of use of nontraditional cancer therapies would provide a clue to the ingestion of Laetrile or other cyanogen-containing preparations. Victims of homicide do not provide a history of exposure. Accidental or suicidal ingestions of cyanide-containing commercial products, such as metal polishes or acetonitrile-containing solvents, have been associated with severe cyanide toxicity.13 Careful identification of ingestants in asymptomatic patients will prevent the mistaken discharge of a patient who has ingested a compound with delayed toxicity.13

Cyanide-poisoned patients frequently present to emergency departments without any history of exposure. Although isolated individual poisonings with cyanide are relatively rare, it is important that emergency physicians recognize signs of serious poisoning because specific antidotal treatment is available and effective. Rapid onset of symptoms is an important clue. Cyanide salts are caustic and may cause oral burns when concentrated solutions or undiluted salts are ingested. A deeply comatose, acidotic patient without evidence of cyanosis or hypoxia on arterial blood gas examination should cause the clinician to think of cyanide. The finding of bright red retinal vessels, an elevated venous oxygen saturation, oral burns, or the smell of bitter almonds supports the diagnosis, although clues of this nature are elusive. It is estimated that only 20 to 40 percent of the population can detect the characteristic almond odor of cyanide.

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