What is it?

• Colorless gas, crystal & solid form
• Rapidly lethal
• Bitter almond smell

Where does it come from? 

• Combustion of products that contain carbon & nitrogen
• Fires! Burning of insulation, fabrics, plastics
• Industrial: Mining, Jewelers (putting metal coat on), photography, rubber/ plastic, manufacturing, pesticides
• Food: Pits & seeds of rosacea family (laurell cherry, bitter almonds, apricot, plum, peach pear)
• Medicine: Sodium Nitroprusside, Amygdalin (alternative medicine chemotherapy)
• Illicit PCP Synthesis, nail polish, cigarrettes

What's it do?

• Inhibits Fe3+ portion of cytochromoe oxidase which is final enzyme in Electron Transport Chain
• Inhibits Oxidative Phosphorylation --> No ATP production --> Anaerobic Metabolism --> Lactic Acidosis
• Induces neuronal apoptosis 
• Some affinity for Fe2+ --> Binds Hemoglobin 

Clinical:

• Greatest effects on CNS, CV
• Decreased conciousness, loss of conciousness, seizure
• Bradycardic, Hypotensive
• Initially Tachypneic followed by Apnea 
• Normal Pulse Oximetry reading as problem is not with circulating O2, problem is with utilization 
• Suspect in UNEXPLAINED LACTIC ACIDOSIS

Management:

• Hydroxycobalamin 
• Binds CN and removes from cytochrome oxidase, excreted by kidney 
• Effective, cheap, safe
• Can cause reddish discoloration of skin, urine, mucus membranes
• Amyl Nitrate (inhaled), Sodium Nitrate (IV)
• Induces Methemoglobinemia
• Can cause hypotension but not a contraindication 
• Contraindicated if suspected concurrent carbon monoxide poisoning patient (fire)
• Thiosulfates
• Enhances bodies naturial elimination process
• Minimal effect on own; combine with one of the above options