Cyanide Intoxication

Medical Faculty of Trisakti University Jakarta

Background
‡ There are a lot of substances that may cause someone experiencing a poisoned until it brings a death. ‡ Substances that active chemically and physiology in one body, at the point of certain dose (toxic) will bring an unhealthiness or may cause a death. ‡ Forensic discuss about toxic substance from its varies, symptoms caused, and method forensic examination to handle either for alive or dead victims.

Scope of Matters
‡ Toxicology definition and factors that affect toxicity ‡ Epidemiology, signs and symptoms, pharmacokinetic, laboratory examination, and treatment/therapy of cyanide poisoning ‡ Forensic examination of patient that experiencing common poison and cyanide poison ‡ medikolegal aspects of deliberate poisoning or unintentionally ‡ Example case of cyanide poisoning

Toxicology Definition
‡ As a part of medical science that focused on toxic ‡ Study about nature and mechanism of toxic effect, varies substance towards living things and other biologic system ‡ A study about source, characteristic and a savor from toxic, indication and treatment against poisoning and other abnormality found in dead victim

Toxic Definition

A substance that may cause bad effect when it gets into a body of a living things, either intentionally or unintentionally

Toxic
‡ Origin: ‡ Plants (opium, cocaine, curare, aflatoxin) ‡ Animals (poison/snake toxin, spider/marine animals) ‡ Mineral (arsenic, plumbum, and things that made from synthetic) ‡ Heroin

Toxic
‡ Venue: ‡ Nature-free (poison gas in nature, household) ‡ Poison agriculture (insecticides, herbesida, pestici des) ‡ Toxic industrial laboratories and industry (acid and strong base, heavy metals) ‡ Toxic food(CN in cassava, botulinus toxic, preservative, additives substance and toxic in the form of medicine e.g. sedative hypnotic)

Toxic
‡ Organs that affected: Hepatotosik Nephrotoxic ‡ Work mechanism: Toxic that bind sulfhydryl group (Pb) Effect on ATP-ase Forming methemoglobin (nitrate and nitrite) ‡ The effects: Local Systemic local-systemic

Exposure to toxic substances on humans and living things: ‡ regular consumption ‡ exposure from work ‡ environmental exposure and poisoning, either intentionally or unintentionally

Factors that affect poisoning:
‡ ‡ ‡ ‡ ‡ How to enter: Age Body condition Habits Idiosinkrasi and allergic to vitamin E, penicilin, streptomycin dan procaine Time delivery

Cyanide
‡ A deadly toxic substance Effects are very fast and can cause death within a few minutes Hydrogen cyanide (formonitrile) In the form of liquid > prussit acid and hydrocyanic acid Liquids can also be colorless or pale blue at the temperature of normal room volatile and flammable diffuse either by air and explosives Very easy to mix with water Otherforms: sodium cyanide and potassium cyanide (powder and white)

Epidemiology
‡ a major contributor to morbidity and mortality, observed in approximately 5,00 0 to10,000 deaths occur from inhaling fog each year in the united states ‡ Exposure suicide rarely reported to poison centers and 18 of 242 (in 2007) and 25 of238 (in 2008) cases of cyanide poisoning is deliberate exposure as reported to the American Association of Poison Control Centers ‡ fatal suicide in adult patients may easily be associated with sudden death from myocardial infarction, pulmonary embolism, or ventricular dysrhythmias

Source
‡ Low-dose in nature and in every product that we usually eat or use ‡ Cyanide can be produced by bacteria, fungi and algae ‡ Cyanide is found in cigarettes, motor vehicle fumes, and food and the synthetic product ‡ Cyanide in seed plants,especially grains (cassava wild, wild tubers, Intersection buffoonery, wild cherry, plum, apricot, wild amigdalin, jetberry bush, etc.)

Exposures
‡ ‡ ‡ ‡ ‡ Fog Inhalation Intentional poisoning (suicide) Industry exposure Iatrogenic exposure Consumption of Supplements Containing Cyanide (Uncommon)

Pharmacokinetic
‡ Cyanide in the body will inactive some oxidative enzymes radically the whole system, especially cytochrome oxidase by binding to the ferric heme group from the oxygen carried by blood ‡ The process of oxidation and reduction occurs as follows: ‡ Cytochrome oxidase Fe + + Fe + + + cytochrome oxidase + CN /---- Fe + + + cytochrome oxidase-cyanideOxidize cyanide d in the body get into cyanates and sulfosianat and expelled from the body through urine. Toxic dose orally for HCN is 60-90 mg, while doses toxic to KCN or NaCN is 200 mg.

Signs and Symptoms
‡ Main effects: hypoxia system arise progressively Symptoms and physical signs that found are depend on the The dose of cyanide Number of exposures Type of exposure Types of cyanide component ‡ symptoms in the body: blood pressure, vision, lung, central nerve, heart, endocrine system, autonomic system and metabolic system sore eyes because of irritation and difficulty breathing due to irritate the respiratory tract mucosa high concentrations only within 15 seconds hiperpnea, 15 seconds to lose consciousness. 3 minutes of apnea is a period of 58 minutes will cause the heart muscle activity is hampered due to hypoxia and ends with death

Exposure of hydrogen cyanide may cause irritation against eyes an d skin immediately after exposure or at least 30 to 60 minutes ‡ In low concentrations, the effects of cyanide emerging about 15-30 minutes later ‡ Early signs of cyanide poisoning: Temporary hiperpnea Headache dyspnea Anxiety Changes in behavior such as agitation and restlessness Sweating a lot, reddish skin color, body feels weak and vertigo

cyanosis of the face, the foam out from the mouth, rapid and weak pulse, rapid breathing and sometimes irregular, dilated pupils and slo wer reflex, air breathing smells tonsil, the vomit also smells By the death, cyanosis more real and arise twitc h muscles and convulsions with urinary incontinence and alvi

Inhalation: palpitations, difficulty to breath, nausea, vomiting, headache, salvasi,lakrimasi, mouth and throat irritation , dizziness and weakness of extremities arise quickly and then collapse, convulsions, coma and dea th Chronic poisoning victim looks pale, cold sweats, dizziness, discomfort in the stomach, nausea and colic, feel pressed on the chest and shortness of breath. Signs the end: coma and dilated pupils, tremors, arrhythmias, co nvulsions, coma emphasis on the respiratory center, respiratory failure until the heart stop beating color skin looks "cherry-red"

Examination
‡ Filter paper test ‡ Reaksi Schonbein Pagenstecher (Guajacol Reaction) ‡ Prussian Blue Reaction ‡ Micro Method Gittler & Golabaum

Therapy
Poisoned by CN inhalation: ->move victim to the place where clean air is available, give-amyl nitrite with inhalation, 1 ampoule (0.2 ml) every5 minut es, stop giving when the systolic blood pressure is less than 80 mmHg -> give artificial respiration with 100% oxygen ->Antidotum in the form of sodium nitrite 3% IV -> vary the dose of sodium nitrite and sodium thiosulfate with Hb

‡ CN poisoning ingested do an emergency action with inhalation of amyl nitrite, one ampoule (0.2 ml,within 3minutes) every 5 minutes Give artificial respiration with 100% oxygen. Besides nitrite, methylene blue 1% 50 mL IV can be used as antidotum

Forensic Medical Examination
‡ cases of deaths due to poisoning: Examination at the place of incident Outdoor examination - smell - Clothes - Bruises corpse - Changes in skin color - Nails - Hair - sclera

Body Surgery
‡ Open chest and abdominal cavity, specify whether there is an unusual smell (smell of poison) Consider the color of blood and the color of organs is brown reddish In lung, there is an acute damming

Material Sampling for Toxicology Examination ‡ Taking blood from the heart separately from the right and left respectively for about 50 ml Blood side for about 30-50 ml, taken from of iliac vein Urine and gastric washings all of taken from the bladder Organ liver should be taken after reserved for pathology anatomy examination

Kidneys should be taken both Brain, lipoid system inside another way to take samples: Get the place where toxic gets in (stomach, the injection site) Blood Out point (urine, bile)

Medical Forensic Examination for Cyanide Poisoning
-Examination of the exterior of the body -> wafted of tonsils -Cyanosis of the face and lips, foam out of the mouth, and bruised corpse light colored -Surgical examination of the corpse -> wafted of specific tonsils distinctive when opening the chest cavity , stomach, brain and also stomach, blood, muscle and body sections color seems red bright

Medikolegal Aspects
KUHP :

Article 205 Article 359 Article 360
KUHAP

Article 133 

Law Number 8 Year 1999 About Consumer Protection: ‡ Article 19 ‡ Article 60 Law Number 7 Year 1996 About Food: Article 21 Government Regulation Number 28 Year 2004 About Safety, Quality and Nutritional Food : Article 25

CASE
‡ Six People is being poisoned by Cyanide Acid in Tiwul (a food from cassava flour) ( Tue, January 18 2011 ) ‡ TEMPO Interaktif, Jepara - Substance Acid cyanide (HCN) became the major cause the death of six victims, children of J (45) by SJ (40): L (24), AA (3), AK (5), MH (13) , F (15) and SK (8) residents of Desa Jebol, District Mayong, Jepara, Central Java, where H CN poisoning their food named tiwul(food from cassava flour)

Case Discussion

Leaf and Cassava Tuber

Be poisoned

Closing
‡ Toxicology can be defined as a substance that can cause bad effect when it gets into a living body, either accidentally or with intent. One type of poisoning that occurs is cyanide poisoning, because the cyanide salt in a small dose is enough to cause death in someone quickly like a suicide. Poisoning can through parenteral administration, inhalation, ingestion or skin absorption (dermal). Signs and symptoms depend on the mechanism, source and quantity of cyanide that gets into the body.

Forensic through the postmortem examination and toxicology tests can prove the existence of cyanide in the body, or any changes and abnormalities consis tent with cyanide poisoning. Aspect medikolegal about cyanide poisoning regulated in KUHP articles 205, 359, 360; KUHAP 133, Law No. 8 of 1999 about consumer protection Article 19 and 60.