Medical Faculty of Trisakti University

Jakarta

Cyanide Intoxication

BackgroundMany 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 MattersToxicology definition and factors that affect

toxicityEpidemiology, 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 DefinitionAs a part of medical science that focused

on toxicStudy 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

ToxicOrigin:Plants (opium, cocaine, curare, aflatoxin)Animals (poison/snake toxin, spider/marine

animals)Mineral (arsenic, plumbum, and things that

made from synthetic)Heroin

ToxicVenue:Nature-free (poison gas in nature, household)Poison agriculture (insecticides, herbesida, pe

sticides)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)

ToxicOrgans 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 andliving things:

regular consumptionexposure from workenvironmental exposure and poisoning, either

intentionally or unintentionally

Factors that affect poisoning:

How to enter:AgeBody conditionHabitsIdiosinkrasi and allergic to vitamin E,

penicilin, streptomycin dan procaineTime delivery

CyanideA 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 5,000 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

SourceLow-dose in nature and in every product that

we usually eat or useCyanide can

be produced by bacteria, fungi and algaeCyanide is found in cigarettes, motor vehicle

fumes, and food and the synthetic productCyanide in seed plants,especially grains (cass

ava wild, wild tubers, Intersection buffoonery, wild cherry, plum, apricot, wild amigdalin, jetberry bush, etc.)

ExposuresFog InhalationIntentional poisoning (suicide)Industry exposureIatrogenic exposureConsumption

of Supplements Containing Cyanide (Uncommon)

PharmacokineticCyanide 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.

Signs and SymptomsMain 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

• 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

• cyanosis of the face, the foam out from the mouth,  rapid and weak pulse, rapid breathing and sometimes irregular, dilated pupils and slower 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

•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 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, convulsions, coma emphasis on the respiratory center, respiratory failure until the heart stop beating• color skin looks "cherry-red"

TestPaper filter testReaksi Schonbein – Pagenstecher ( Reaksi

Guajacol)Prussian Blue reactionMicro 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 minutes, 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 Examinationcases 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 SurgeryOpen

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 brownreddish • In lung, there is an acute damming

Material Sampling for Toxicology ExaminationTaking 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)BloodOut point (urine, bile)

Pemeriksaan Kedokteran Forensik Keracunan Sianida• pemeriksaan bagian luar jenazah

tercium bau amandel• Sianosis pada wajah dan bibir, busa keluar

dari mulut, dan lebam mayat berwarna terang

• pemeriksaan bedah jenazah tercium bau amandel yang khas pada waktu membuka rongga dada, perut dan otak serta lambung, darah, otot dan penampang tubuh dapat berwarna merah terang

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 the spesific tonsils distinctive when opening the chest cavity stomach, brain and also blood, muscle, and body sections color seems red bright

Medikolegal AspectsKUHP :

Article 205Article 359Article 360

KUHAP Article 133

Law Number 8 Year 1999 About Consumer Protection:

Article 19Article 60Law Number 7 Year 1996 About Food:

Article 21Government Regulation Number 28

Year 2004About 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 HCN poisoning their food named tiwul(food from cassava flour)

Leaf and

Cassava Tuber

Be poisoned

Case Discussion

ClosingToxicology 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 post-mortem examination and toxicology tests can prove the existence of cyanide in the body, or any changes and abnormalities consistent 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.

Bibiliography   Budiyanto A, Widiatmaka W, Sudiono S,et al. Ilmu Kedokteran

Forensik. Jakarta : Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia. 1997, hlm 71-72

Ernest H. A Textbook of Modern Toxicology Third Edition. New Jersey : A John Wiley & Sons, Inc, 2004, hlm 3-8

Budiyanto A, Widiatmaka W, Sudiono S, et al. Ilmu Kedokteran Forensik, 1997. Jakarta : Bagian Kedokteran Forensik Universitas Indonesia ; 95 – 100.

Leybell I, Borron SW. Cyanide Toxicity. June 2nd 2010. Cited from : http://emedicine.medscape.com/article/814287

Budiyanto A, Widiatmaka W, Sudiono S, et al. Ilmu Kedokteran Forensik, 1997. Jakarta : Bagian Kedokteran Forensik Universitas Indonesia ; 73 – 86

Kitab Undang-undang Hukum Pidana Kitab Undang-undang Hukum Acara Pidana Undang-undang Nomor 8 tahun 1999 Tentang Perlindungan

Konsumen Undang-undang Nomor 7 tahun 1996 Tentang Pangan Centers for Disease Control and Prevention. The Facts About

Cyanides. New York State Department Of Health. New York. 2004. Available from: www.health.state.ny.us/nysdoh/bt/chemical_terrorism/docs/cyanide_general.pdf. Access on: November 29, 2006

http://gresnews.com/ch/Regional/cl/hisyam-alie/id/1810889/Enam-Tewas-Keracunan-Asam-Sianida-Pada-Tiwul