Objective: Cyanide intoxication is an extremely rare event. We report a case of a teenager presenting with unresponsiveness, hemodynamic instability, and profound anion gap metabolic acidosis secondary to elevated lactate levels. It was later confirmed that he was a victim of cyanide poisoning.
Design: Individual case report.
Setting: Pediatric intensive care unit of a tertiary care hospital.
Patient: A 17-yr-old male presented with seizures, apnea, and cardiovascular collapse. His laboratory evaluation revealed extreme anion gap metabolic acidosis, elevated lactate levels, and absent arteriovenous saturation difference.
Interventions: The patient required inotropic support and external cardiac pacing for hemodynamic instability. Serial measurements of electrolytes and arterial and central venous blood gases were performed. When cyanide poisoning was suspected he received antidote therapy, administered initially with interval dosing and then as a continuous infusion. The antidote infusions were stopped because of a high level of resultant methemoglobinemia and the belief that all ingested cyanide had been cleared, given the time from exposure. The patient never recovered neurologic function, was declared brain dead, and became a tissue and organ donor.
Conclusion: Cyanide poisoning is a rare and potentially fatal event. Prompt recognition of its possibility in a critically ill patient can lead to early intervention with antidote therapy and decrease the extent of morbidity and mortality.