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.