In summary, the index must be raised to the point of suspicion or a look at fire smoke from the point of view of fire prevention. We need to be more aggressive and serious about how we approach preclinical care. We will also need ways to see how we can identify it in the field a bit easier. At present, some scientific studies are being conducted in Asia looking for markers for lactate levels in the field of preclinical care. They also deal with different types of electronic technologies.
We need to improve this way of identifying cyanide in preclinical care. And most of all, we need to increase our air management problem with our firefighters so we can at least get them out of the way while trying to save other people's lives.
In addition, we must dispel some of the common perceptions about cyanide, especially inhalation of smoke. There will be a real need for more research and for emergency physicians and physicians to be more serious about this issue.
Our next lecture Bogdan will talk a little more about the pathophysiology of cyanide and the available antidotes.
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Behind the Smoke Wall: The Science of Cyanide and Fire Smoke Poisoning
Gregory M. Bogdan, PhD: Chief Walsh has already talked about the different products that are used in residential buildings and how many of them can release cyanide when burned.
First, we will talk about a Dallas study authored by Silverman and co-workers and published in 1988. The study was conducted to determine the incidence and clinical significance of cyanide toxicity in people exposed to smoke and fire, and also consider relationships with morbidity and mortality.
The study had 144 patients prospectively examined for inhalation or exposure to smoke. The study period lasted from August '84 to June '86. They also looked at several other factors, such as the history of smoking, materials involved in fires, and whether they were internal / external fires. The labs drawn to the patient in this study were performed within 8 hours.
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This slide shows the levels of blood cyanide in milligrams per liter (mg / L) plotted on the Y-axis and shows two groups. The victims who were alive on arrival were the 144. A comparable group were also persons who were actually dead on arrival at the medical examiner's office, and there were 43 in that group.
A cyanide content of 0.1 mg / L or less is considered normal. There is something cyanide in all of us. If you are a smoker, your blood cyanide content is probably a little higher than for those who do not smoke. When you start to reach a level of 0.5 mg / L to 1 mg / L, you fall into the toxic range. And a level of 2 mg / L to 3 mg / L would be considered fatal.
You can see that the victims were alive on arrival. Their mean content was 0.65 mg / l. That starts to bring them into the toxic area. Compared to those who died on arrival or were dead, their level was far beyond deadly.
The carboxyhemoglobin level for the on-the-alive group was 8% on average, compared to the subjects who were dead, corresponding to a mean of 52%. Those who died had high cyanide levels as well as high carboxyhemoglobin levels, also indicating carbon monoxide toxicity.
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In summary, elevated cyanide levels are common in these patients with smoke inhalation. The results suggest that toxicity contributes to death and that in some cases inhaled smoke cyanide is the primary poison measured.
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