Case presentation
A 39 year old male patient was brought to the emergency department with
severe nausea and vomiting proceeding the intentional ingestion of two
spoons full of cyanide salt that was obtained from a friend working in
the jewelry industry. The time of ingestion was seven hours before
admittance. Immediately after the ingestion of the powder, gastric
irrigation and activated charcoal administration was undertaken in a
primary health care facility and was then referred to our emergency
department due to the development of refractory nausea and severe
vomiting.
Upon arrival the patient has an oral temperature of 37.2 degrees
Celsius, pulse rate of 110 beats per minute, respiratory rate of 18
breaths per minute, blood pressure recording of 110/70 and a Glasgow
coma scale (GCS) score of 15. Pulse oximetry showed 97%. Peripheral
perfusion assessment was Physical examination other than an evident
tachycardia was otherwise normal. The patients reported tobacco use but
no history of alcohol abuse or addiction to illicit drugs.
After admittance to the emergency department primary blood work revealed
leukocytosis and metabolic acidosis (lab data are summarized in table
1). ECG of the patient showed normal sinus rhythm and tachycardia.
An intravenous line was obtained and hydration and other supportive
measures were started. After hours blood pressure recordings dropped to
67/35 and peripheral perfusion was decreased. Due to the history
obtained from the patient and the metabolic acidosis and hypotension,
cyanide poisoning was suspected. As cyanide antidote kits were not
available at our center, management consisted of norepinephrine 10-20
mcg/min, bicarbonate, and 2 sessions of plasmapheresis. Each
plasmapheresis session was 3 hours. In the first session 3 liters of
plasma were replaced with 2300 cc normal saline and 700 cc fresh frozen
plasma and in the second session 3 liters of plasma was replaced with
2200 cc, 700cc, and 2 vials of normal saline, FFP, and albumin
respectively.
After the completion of plasmapheresis sessions hypotension and acidosis
were resolved. VBG measurements are summarized in table 2. The patient
recovered completely after two days and was discharged.