Management of cyanide poisoning 

Acute cyanide poisoning poses vital diagnostic and therapeutic challenges for emergency physicians and intensivists. While it presents certain unique clinical features, cyanide poisoning may be confused with other entities. Definitive, contemporaneous diagnosis at the bedside is impossible in most hospitals. A thorough anamnesis, rapid physical assessment, and evaluation of key laboratory indicators often point the clinician in the right direction. Smoke inhalation from structure fires represents the most frequent source of cyanide poisoning. Symptom onset may be gradual in the case of skin exposures to cyanide or ingestion of compounds that are metabolized to cyanide. However, acute cyanide poisoning presents as a syndrome of rapidly evolving and deteriorating vital signs, profound neurological and cardiovascular dysfunction, and if therapeutic interventions are not timely and adapted, death. There is little time for diagnostic testing: one must act! The sine qua non of treatment is excellent supportive care, with aggressive airway management, support of blood pressure, and correction of acidosis. Treatment of acidosis is particularly relevant in the case of cyanide. Rapid administration of specific cyanide antidotes may be lifesaving. While geographic variations exist in antidote availability, most commercially available antidotes have been demonstrated to be effective. Hydroxocobalamin and sodium thiosulphate, both safe in the setting of smoke inhalation, offer the highest therapeutic index, a critical consideration when the diagnosis is uncertain.