Cyanide intoxication

1. Cyanide Intoxication
Medical Faculty of
Trisakti University
Jakarta

2. 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.

3. 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

4. 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

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

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

7. 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)

8. 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

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

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

11. 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)

12. 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

13. 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.)

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

15. 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-cyanide-
Oxidize 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.

16. 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 5-
8 minutes will cause the heart muscle activity is hampered due
to hypoxia and ends with death

17. • Exposure of hydrogen cyanide
may cause irritation against eyes
and 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

18. • cyanosis of the face, the foam out from the
mouth, rapid and weak pulse, rapid breathing
and sometimes irregular, dilated pupils and sl
ower reflex, air breathing smells
tonsil, the vomit also smells
• By the death, cyanosis more real
and arise twitch muscles and convulsions
with urinary incontinence and alvi

19. •Inhalation: palpitations, difficulty to
breath, nausea, vomiting,
headache, salvasi,lakrimasi, mouth and throat irritatio
n, dizziness and weakness of extremities arise quickly
and then collapse, convulsions, coma and death
• 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, convuls
ions, coma emphasis on the
respiratory center, respiratory failure until the heart
stop beating
• color skin looks "cherry-red"

20. Examination
• Filter paper test
• Reaksi Schonbein – Pagenstecher (Guajacol
Reaction)
• Prussian Blue Reaction
• Micro Method Gittler & Golabaum

21. 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

22. • 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

23. 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

24. 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

25. 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

26. • 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)

27. 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

28. Medikolegal Aspects
KUHP :
Article 205
Article 359
Article 360
KUHAP
Article 133

29. 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

30. 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)

31. Leaf and
Cassava
Tuber
Be poisoned
Case Discussion

32. 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.

33. • Forensic through the post-
mortem 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.