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Cyanide and Methemoglobinemia. Presented by: Dr. Aric Storck Preceptor: Dr. Ingrid Vicas Core Rounds February 20, 2003. Cyanide. Cyanide. Anion (CN - ) solid and gaseous forms Important component of many industrial reactions mining - recover silver and gold from ores

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Cyanide and methemoglobinemia

Cyanide and Methemoglobinemia

Presented by: Dr. Aric Storck

Preceptor: Dr. Ingrid Vicas

Core Rounds

February 20, 2003



Cyanide1
Cyanide

  • Anion (CN-)

  • solid and gaseous forms

  • Important component of many industrial reactions

    • mining - recover silver and gold from ores

    • photographic - recovery of silver

    • plastic manufacturing

  • Naturally occurs in many plant products

    • Tobacco, apricot pits


Cyanide pollution
Cyanide pollution

  • 1997 - 4,513,410 cyanide released by top 100 polluters in USA

  • Bhopal, 1984

    • worst industrial poisoning in history

    • 25,000 kg methyl isocyanate and combustion products released into atmosphere

    • 1,800 - 5,000 deaths

    • 200,000 injuries


Man carries his wife past the Union Carbide factory in Bhopal, India. Fumes from the factory killed her the previous day

Source: Greenpeace


Skulls from victims of the Union Carbide disaster in the Hamidia Hospital in Bhopal, India.

Source: Greenpeace


Cyanide a potential disaster
Cyanide … a potential disaster Hamidia Hospital in Bhopal, India.

  • 500,000 hazardous materials shipments / day in the USA

  • Average 12,115 hazardous material accidents per year (1990-1996)

  • Large potential for significant industrial accident involving cyanide


Cyanide and terrorism
Cyanide and terrorism Hamidia Hospital in Bhopal, India.

  • 1984 - 7 Chicago area residents killed after ingesting cyanide-laced Tylenol

  • Cyanide gas precursors (cyanide salt + acid) found in Tokyo subway bathrooms following sarin gas attacks

  • Cyanide believed to be involved in World Trade Center bombing (incinerated in attack)


Cyanide and fires
Cyanide and Fires Hamidia Hospital in Bhopal, India.

  • Cyanide is a combustion product of

    • plastic

    • rugs

    • silks

    • furniture

    • construction materials


Cyanide and fires1
Cyanide and Fires Hamidia Hospital in Bhopal, India.

  • Significant correlation between CO levels and CN- levels in fire victims

  • estimated 35% of fire victims have toxic levels of cyanide

Source: Sauer S, Keim M. Hydroxocobalamin: Improved public health readiness for cyanide disasters. Ann Emerg Med. June 2001; 37:635-641.


Cyanide pathophysiology
Cyanide - Pathophysiology Hamidia Hospital in Bhopal, India.

  • CN- has high affinity for metals

    • Complexes with metallic cations at catalytic sites of several enzymes

  • Binds ferric (3+) iron of mitochondrial cytochrome oxidase (cytochrome a-a3)

  • cytochrome a-a3 – mediates transfer of electrons to molecular oxygen (final step in oxidative phosphorylation)


Oxidative Phosphorylation Hamidia Hospital in Bhopal, India.

Source: Ford’s Clinical Toxicology


Blockade of oxidative phosphorylation
Blockade of oxidative phosphorylation Hamidia Hospital in Bhopal, India.

  • Tissue anoxia

  • Anaerobic metabolism

  • Lactic acidosis


Cyanide pathophysiology1
Cyanide - Pathophysiology Hamidia Hospital in Bhopal, India.

  • Other metabolic effects

    • Less relevant (...because you die of anoxia first)

    • Interferes with lipid metabolism

    • Interferes with glycogen metabolism


Cyanide poisoning
Cyanide - Poisoning Hamidia Hospital in Bhopal, India.

  • Rapid absorption

    • Respiratory tract

    • Mucous membranes

  • Slow absorption

    • Skin

    • GI tract


Cyanide poisoning inhalation
Cyanide Poisoning - Inhalation Hamidia Hospital in Bhopal, India.

  • Hydrogen cyanide

    • Combustion of nitrogen containing polymers (vinyl, polyurethane, silk)

  • Immediate onset of symptoms

    • 50 ppm

      • Symptoms after several hours

      • Anxiety, SOB, palpitations, headache

    • 100 ppm

      • Death after 30 minutes

    • 270 ppm

      • Immediate coma, asystole, death


Cyanide ingested salts
Cyanide – Ingested Salts Hamidia Hospital in Bhopal, India.

  • Symptoms within minutes

  • Caustic – oral burns

  • Smell of bitter almonds

  • 50 mg – has been reported to cause death

  • LD50 – 140-250 mg (untreated adult)


Ingestion cyanide producing compounds
Ingestion – Cyanide producing compounds Hamidia Hospital in Bhopal, India.

  • Compounds require metabolic activation to produce cyanide

    • Organic nitriles

    • Cyanogenic glycosides

      • eg: amygdalin – found in bitter almonds, apricot pits

        • Hydrolyzed to CN in small bowel

        • Not toxic if taken intravenously

      • Acetonitrile (solvent in artificial nail remover)

        • Oxidized by hepatic enzymes

  • Delayed onset of symptoms (up to 24 hours)


Cyanide dermal exposure
Cyanide - Dermal Exposure Hamidia Hospital in Bhopal, India.

  • LD50 = 100 mg/kg


Cyanide nitroprusside
Cyanide & Nitroprusside Hamidia Hospital in Bhopal, India.

  • Deterioration in aqueous solutions releases cyanide

  • Hydroxycobalamin and thiosulfate co-infusions used in critical care settings


Chronic cyanide poisoning
Chronic Cyanide Poisoning Hamidia Hospital in Bhopal, India.

  • Clinical relevance controversial

  • Cassava – contains linamarin (cyanogenic)

    • Common food in many countries

    • Some evidence that B12 deficiency, goiter, demyelinating diseases may be related


Cyanide detoxification
Cyanide - Detoxification Hamidia Hospital in Bhopal, India.

  • Naturally occurs in small quantities

    • tobacco

    • cassava

  • Small amounts routinely cleared from body


Cyanide detoxification1
Cyanide - Detoxification Hamidia Hospital in Bhopal, India.

  • Cyanide + thiosulfate = thiocyanate

    • Enzymatically

      • Rhodanase

      • Beta-mercaptopyruvate-cyanide sulfur transferase

    • Nonenzymatically

      • Sulfane-albumin complex combines with cyanide


Cyanide elimination
Cyanide - Elimination Hamidia Hospital in Bhopal, India.

  • Thiocyanate

    • Relatively non-toxic

    • Renal elimination (half life 2.5 days)


Cyanide clinical presentation
Cyanide – Clinical Presentation Hamidia Hospital in Bhopal, India.

  • Physiologic manifestations of hypoxia

    • Metabolic acidosis

    • Bradycardia

    • Dyspnea

    • CNS disturbances

  • Normal pulse oximetry


Cyanide clinical presentation1
Cyanide – Clinical Presentation Hamidia Hospital in Bhopal, India.

  • CNS

    • Headaches

    • Drowsiness

    • Dizziness

    • Seizures

    • Coma


Cyanide clinical presentation2
Cyanide – Clinical Presentation Hamidia Hospital in Bhopal, India.

  • Pulmonary

    • Dyspnea

    • Tachypnea

    • Apnea


Cyanide poisoning ddx
Cyanide Poisoning - DDX Hamidia Hospital in Bhopal, India.

  • Ingestion with altered LOC and acidosis

    • sodium azide

    • salicylates

    • iron

    • Beta-adrenergic antagonists

    • cocaine

    • isoniazid

    • toxic alcohols


Cyanide poisoning ddx1
Cyanide Poisoning - DDX Hamidia Hospital in Bhopal, India.

  • Inhalational Exposures

    • hydrogen sulfide

    • carbon monoxide

    • simple asphyxiants


Cyanide clinical presentation3
Cyanide – Clinical Presentation Hamidia Hospital in Bhopal, India.

  • Cardiovascular Effects

    • Hypertension

    • Tachycardia

    • Hypotension

    • Bradycardia

    • Asystole

    • Cardiac collapse


Laboratory investigation
Laboratory Investigation Hamidia Hospital in Bhopal, India.

  • Electrolytes

    • Elevated anion gap (lactic acidosis)

  • ABG

    • Metabolic acidosis (lactic acidosis)

    • Normal PO2

  • SaO2

    • Normal


Laboratory investigation1
Laboratory Investigation Hamidia Hospital in Bhopal, India.

  • AVO2

    • Decreased (decreased tissue oxygen utilization)

  • Cyanide levels

    • Not rapid enough for clinical utility

    • Serum cyanide level

      • Toxic = >0.5mg/L

      • Fatal = >3.0 mg/L

    • Erythrocyte cyanide level

      • Normal = <1.9 uM/L (50ug/L)

      • Fatal = > 40 uM/L (1mg/L)


Laboratory investigation2
Laboratory Investigation Hamidia Hospital in Bhopal, India.

  • Serum lactate – elevated

  • ECG

    • Sinus bradycardia

    • Sinus tachycardia


Cyanide poisoning sequellae
Cyanide Poisoning - Sequellae Hamidia Hospital in Bhopal, India.

  • Directly related to severity of exposure and delay in treatment

  • long term sequellae are those of hypoxia

    • cerebral hypoxia / encephalopathy (common)


Cyanide treatment
Cyanide - Treatment Hamidia Hospital in Bhopal, India.

  • Monitors

  • IV access

  • Administer 100% O2

  • Gastric lavage

    • Indicated in very recent ingestion

  • Activated charcoal (1g/kg)


Cyanide antidote kit
Cyanide Antidote Kit Hamidia Hospital in Bhopal, India.

Manufacturer: Taylor Pharmaceuticals

Cost: $317 USD


Cyanide antidote kit1
Cyanide Antidote Kit Hamidia Hospital in Bhopal, India.

  • Contents

    • Amyl nitrite 0.3 ml x 12

      • Inhaled while IV access established

      • Not necessary if immediate IV access

      • Can be given in pre-hospital setting

    • Sodium nitrite 300mg/10cc x 2

    • Sodium thiosulfate 12.5g/50cc x2

    • syringes, needles, tourniquet, stomach tube, instructions


Cyanide antidote kit2
Cyanide Antidote Kit Hamidia Hospital in Bhopal, India.

  • Instructions

    • Crush and inhale one ampoule (0.3ml) of amyl nitrite q15-30 seconds until iv access achieved

    • Rapid infusion sodium nitrite 300mg

    • Infuse sodium thiosulfate 12.5g over 10 minutes

    • Repeat sodium nitrite and thiosulfate infusion at half dose prn x 1

  • Caution

    • Sodium nitrite infusion limited by hypotension


Cyanide antidote kit mechanism
Cyanide Antidote Kit - Mechanism Hamidia Hospital in Bhopal, India.

  • Nitrites

    • Therapeutic induction of methemoglobinemia

      NO2 + Hb = MHb

    • Methemoglobin binds strongly to CN- and removes it from tissues

      CN- + MHB = cyanomethemoglobin

    • cyanomethemoglobin relatively non-toxic


  • Sodium Thiosulfate Hamidia Hospital in Bhopal, India.

    • donates sulfur molecule to rhodanese (enzyme which catalyzes formation of thiocyanate)

      Na2S2O3 + HCN + O = HSCN

    • Synergistic effect

  • Oxygen

    • Synergy of 100% O2 with nitrites/thiosulfate


Cak children
CAK - Children Hamidia Hospital in Bhopal, India.

  • 0.33 mL/kg of 3% NaNO2

    • Adjust dose if anemic

      • Hb 70 – 0.19mL/kg

      • Hb 100 – 0.27mL/kg

      • Hb 120 – 0.33mL/kg

      • Hb 140 – 0.39mL/kg

  • 1.65 mL/kg of 25% Na2S2O3


Cyanide antidote kit3
Cyanide Antidote Kit Hamidia Hospital in Bhopal, India.

  • Effectiveness

    • able to detoxify 20 lethal ingested doses in dogs

    • effective even after respiratory arrest as long as no cardiac arrest

  • Complications

    • Hypotension

      • Related to vasodilatory effects of nitrites

    • Methemoglobinemia

      • Death reported in asymptomatic cyanide poisonings (NB: only use CAK if symptomatic poisoning)


Cyanide antidote kit4
Cyanide Antidote Kit Hamidia Hospital in Bhopal, India.

  • Limitations

    • MHb production prevents its use in unconfirmed cases

    • not practical for smoke inhalation victims (bad idea to induce MHb when already high level of carboxyhemoglobin)

    • many hospitals poorly supplied

      • 81% of Tennessee hospitals unable to treat two 70 kg patients


Cyanide other antidotes
Cyanide – other antidotes Hamidia Hospital in Bhopal, India.

  • Hyperbaric Oxygen

    • No therapeutic effect

    • Useful if concomitant CO inhalation

  • Dicobalt edetate

    • Widely used in UK

    • Effective antidote with significant toxicity (esp. when cyanide not present)


Dmap 4 dimethylaminophenol
DMAP (4-dimethylaminophenol) Hamidia Hospital in Bhopal, India.

  • Produces very rapid methemoglobinemia

  • Used widely in Germany

  • No more effective than sodium nitrite

  • Less hypotension than sodium nitrite

  • Linked with renal failure in animal models


Hydroxycobalamin vitamin b12 a
Hydroxycobalamin Hamidia Hospital in Bhopal, India. (vitamin B12a)

  • Widely used in France

  • Very effective and non-toxic

  • precursor of B12 (cyanocobalamin)

    • ideal choice for vegan victims of cyanide poisoning

  • Recognized by FDA for cyanide poisoning

  • Used in ICU settings to mitigate nitroprusside toxicity


  • Reduces cyanide to cyanocobalamin Hamidia Hospital in Bhopal, India.

    B12a + CN- = B12

  • 5g B12a will treat patients with up to 40 umol/L

  • Low concentrations available in US mean very large quantities required


Hydroxycobalamin vitamin b12 a1
Hydroxycobalamin Hamidia Hospital in Bhopal, India. (vitamin B12a)

  • When combined with sodium thiosulfate end product is thiocyanate

    Na2S2O3 + B12 = HSCN + B12a

    • Recycling of hydroxycobalamin

    • Renally cleared

    • Synergistic effect of thiosulfate and B12a


Hydroxycobalamin vitamin b12 a2
Hydroxycobalamin Hamidia Hospital in Bhopal, India. (vitamin B12a)

  • Advantages vs CAK

    • less toxic

    • does not produce MHb (thus appropriate for smoke inhalation victims)

    • may be administered out of hospital

    • cheaper


Hydroxycobalamin vitamin b12 a3
Hydroxycobalamin Hamidia Hospital in Bhopal, India. (vitamin B12a)

  • Available in Europe as Cyanokit

    • 2.5 and 5.0 g doses

    • very concentrated (5g/100 ml)

  • in USA hydroxycobalamin available in 1mg/mL (5L infusion required for 5g dose)

  • No pharmaceutical company willing to sponsor FDA approval and development in North America


Cyanide poisoning disposition
Cyanide Poisoning - Disposition Hamidia Hospital in Bhopal, India.

  • Symptomatic

    • ICU admision until complete resolution of metabolic acidosis

  • Inhalation exposure

    • Discharge if asymptomatic in ED

  • Cyanide Salt Ingestion

    • Discharge if asymptomatic at 4 hours

  • Cyanogenic glycosides / organonitriles

    • 24 hours of inpatient observation for symptoms

  • Suicidal patients

    • Psychiatric evaluation


Methemoglobinemia

Methemoglobinemia Hamidia Hospital in Bhopal, India.


What is methemoglobinemia
What is methemoglobinemia? Hamidia Hospital in Bhopal, India.

  • Oxidation of iron within heme from Fe2+ to Fe 3+

  • Methemoglobinemia is due to an imbalance of MHb production and MHb reduction


Mhb biochemistry
MHb - Biochemistry Hamidia Hospital in Bhopal, India.

  • Hemoglobin tetrameric molecule

  • 8 different dimers of MHb are produced when exposed to oxidative stress


  • Oxidized (Fe Hamidia Hospital in Bhopal, India. 3+) heme cannot carry oxygen

  • Allosteric changes cause non-oxidized heme to bind oxygen more tightly

    • Left shift of oxygen dissociation curve

    • Thus 30% methemoglobinemia has <70% of original oxygen carrying capacity



Biochemistry continued
Biochemistry, continued … Hamidia Hospital in Bhopal, India.

  • Positively charged MHb has high affinity for negative anions (cyanide, fluoride, chloride)

  • Neutral Hb has high affinity for neutral ligands (CO, O2. CO2)

  • ….thus MHb is not particularly good at transporting oxygen (functional anemia)


Methemoglobinemia etiology
Methemoglobinemia - etiology Hamidia Hospital in Bhopal, India.

  • Spontaneous

  • Congenital

  • Transient (illness associated)

  • Toxic

  • Iatrogenic


Spontaneous methemoglobinemia
Spontaneous Methemoglobinemia Hamidia Hospital in Bhopal, India.

  • Autooxidation of Hb

    • 0.5 - 3% Hb converted to MHb each day

  • Autoreduction of MHb

    • 99% occurs via NADH-dependent cytochrome b5 reductase (b5r) pathway

    • Ascorbic acid, glutathione – minor role in reduction

    • Conversion of MHb to Hb is 15% per hour (assuming no ongoing production)


A. The NADH-dependent cytochrome b5 methemoglobin reductase system (endogenous).

B, The NADPH-dependent methemoglobin reductase system (therapeutic).

Source: Ford: Clinical Toxicology


Congenital methemoglobinemia
Congenital Methemoglobinemia system (endogenous).

  • Hemoglobin M

    • rare autosomal dominant disorder

    • stabilize heme iron in ferric (3+) state

    • death in homozygotes

    • lifelong cyanosis in heterozygotes


Congenital methemoglobinemia1
Congenital Methemoglobinemia system (endogenous).

  • cytochrome b5 reductase deficiency

    • autosomal recessive

    • lifelong cyanosis in homozygotes

      • …but very few symptoms due to other adaptations

    • very sensitive to xenobiotic oxidizing agents

  • cytochrome b5 deficiency

    • very rare

    • autosomal recessive


Congenital methemoglobinemia2
Congenital Methemoglobinemia system (endogenous).

  • NADPH-MHb reductase deficiency

    • exceedingly rare

    • Does not cause MHb

      • Enzyme only reduces MHb in presence of exogenous catalyzing agent (ie: methylene blue)

    • Patient would not respond to therapeutic methylene blue


The fugates of troublesome creek
The Fugates of Troublesome Creek system (endogenous).


Fugate pedigree with genotypes
Fugate pedigree with genotypes system (endogenous).

  • Congenital NADH-diaphorase deficiency


Transient illness associated methemoglobinemia
Transient (illness-associated) Methemoglobinemia system (endogenous).

  • MHb common in septic infants with gastroenteritis and acidosis

  • Infants <6 months

    • NADH-dependent reductase deficiency

    • Presence of fetal Hb

  • Thus infant Hb more prone to oxidative stress

  • Exact mechanism poorly understood

    • altered flora, RTA, low Cl, UTI, protein intolerance ….


Toxic methemoglobinemia
Toxic Methemoglobinemia system (endogenous).

  • side effect of therapeutic drugs

  • environmental

    • nitrates in well water

    • nitrates in spinach, carrots, beets, etc.

  • intentional OD


Toxic methemoglobinemia1
Toxic Methemoglobinemia system (endogenous).

  • Factors influencing degree of MHb

    • rate of entry of oxidant into circulation and RBCs

    • rate of metabolism of toxin in body

    • rate of excretion of toxin

    • effectiveness of cellular MHb reduction systems


Toxins causing mhb

chloroquine system (endogenous).

dapsone

local anaesthetics

methylene blue

metoclopramide

nitrates

nitrites

NTG

nitroprusside

phenacetin

pyridium

primaquine

rifampin

sulfonamides

vitamin K3

chlorhexidine

Toxins causing MHb


Therapeutic methemoglobinemia
Therapeutic Methemoglobinemia system (endogenous).

  • Iatrogenic induction of MHb in cyanide poisoning


Methemoglobinemia diagnosis
Methemoglobinemia - Diagnosis system (endogenous).

  • Physical Exam

    • cyanotic

“Chocolate brown” lips


Symptoms vs mhb concentration
Symptoms vs MHb concentration system (endogenous).


  • Chocolate-brown arterial blood system (endogenous).

  • does not become red with exposure to oxygen

  • filter paper test

    • place drop of blood on filter paper - MHb will not turn red

  • Potassium cyanide test

    • MHb turns red when CN added, sulfhemoglobin does not


ABG system (endogenous).

  • Measured - pH, pCO2, PO2

    • Remember … PO2 refers to dissolved oxygen and has nothing to do with Hb

  • Calculated

    • SaO2 – from normal Hb-oxy dissociation curve

      • Assumes all Hb is normal

      • Abnormal Hb (MHb) which do not interfere with pulmonary diffusion with falsely elevate SaO2

      • “Saturation gap” = measured – calculated sats

        • >5% discrepancy suggests MHb, carboxyhemoglobin, or sulfhemoglobin

    • HCO3 – from Henderson-Hasselbach equation


  • Pulse oximetry system (endogenous).

    • Not accurate in MHb!!

    • Only measures 2 wavelengths: 660 & 940nm

    • 100% MHb will read 85% saturation

  • Co-oximetry

    • Measures four wavelengths

    • Maximal absorption peak at 630-631 nm (little interference from oxyhemoglobin)


Mhb treatment
MHb - Treatment system (endogenous).

  • Mild cases (no overt hypoxia)

    • Supportive care

    • Remove offending agent

    • (half-life of local anaesthetic induced MHb in normal individual = 55 minutes)


  • Severe Cases system (endogenous).

    • overt hypoxia, CNS depression, CVS instability

    • manage more aggressively in patients with coexisting medical problems (CAD, etc.)

    • Recommend antidote for MHb > 30% (or 20% in symptomatic patients)

    • 100% oxygen

    • GI/skin decontamination (charcoal, etc.)


Methylene blue
Methylene Blue system (endogenous).

  • Specific antidote for MHb

  • 1-2 mg/kg over 5 minutes

  • Repeat doses to maximum 7mg/kg


A. The NADH-dependent cytochrome b5 methemoglobin reductase system (endogenous).

B, The NADPH-dependent methemoglobin reductase system (therapeutic).

Source: Ford: Clinical Toxicology


Methylene blue1
Methylene Blue system (endogenous).

  • G6PD deficiency – Contraindication

    • Enzyme used in formation of NADPH

    • Insufficient NADPH produced to reduce methylene blue (oxidizing agent) to leukomethylene blue (reducing agent)

    • Relative buildup of methylene blue (oxidizing agent)

    • Can get paradoxical methemoglobinemia and methylene blue induced hemolysis


  • Ascorbic Acid system (endogenous).

    • 300-1000mg/day iv (divided tid-qid)

    • Nonenzymatic MHb reduction

  • N-acetylcysteine

    • Works in vitro, no in vivo studies yet


Treatment
Treatment system (endogenous).

  • Congenital MHb

    • Generally asymtomatic due to compensatory mechanisms

    • Methylene blue – 100-300mg/day

    • Ascorbic acid – 200-500mg/day

  • Illness associated MHb in infants

    • Supportive care (hydration, etc.)

    • Treat MHb >30%



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