Substances Included Synonyms

Therapeutic Toxic Class

A)

1) Acetone cyanohydrin is used as an intermediate compound in organic synthesis, especially for the production of resins, methyl methacrylate, and insecticides (ITI, 1985; EPA, 1985; (Sax & Lewis, 1987; Clayton & Clayton, 1982).

a) It is also used for transcyanohydrination reactions, such as in the preparation of a 17-monocyanohydrin form of a 3,7-diketo steroid by a hydrogen cyanide exchange with the reagent (Windholz et al, 1983).

2) Acetone cyanohydrin is prepared by adding acetone to an aqueous solution of either potassium or sodium cyanide and then treating the mixture with sulfuric acid at a temperature less than 20 degrees C, or by condensing acetone with hydrocyanic acid (Windholz et al, 1983; Sax & Lewis, 1987).

a) It is shipped as a 98 to 99 percent pure technical grade material (CHRIS, 1985; (Sax & Lewis, 1987).

3) Acetone cyanohydrin readily decomposes to form hydrogen cyanide (Gosselin et al, 1984).

Specific Substances

1) Acetone cyanohydrin
2) Acetoncianidrina (Italian)
3) Acetoncianhidrinei (Rumanian)
4) Acetoncyaanhydrine (Dutch)
5) Acetoncyanhydrin (German)
6) Acetonecyanhydrine (French)
7) Acetonkyanhydrin (Czech)
8) Cyanhydrine d'acetone (French)
9) 2-Cyano-2-propanol
10) Hydroxyisobutyronitrile
11) alpha-Hydroxyisobutyronitrile
12) 2-Hydroxyisobutyronitrile
13) 2-Hydroxy-2-methylpropanenitrile
14) 2-Hydroxy-2-methylpropionitrile
15) Isopropylcyanohydrin
16) Lactonitrile, 2-methyl-
17) 2-Methyl-actonitrile
18) Propanenitrile, 2-hydroxy-2-methyl
19) RCRA WASTE NUMBER: P069
20) USAF RH-8
21) NIOSH/RTECS OD 9275000
22) Molecular Formula: C4-H7-N-O
23) CAS 75-86-5
24) References: RTECS, 1988; EPA, 1985; ITI, 1985;
25) Lederer, 1985; Sax, 1984; Clayton & Clayton,
26) 1982

1.2.1) MOLECULAR FORMULA
1) C4-H7-N-O

Available Forms Sources

A)

1) Acetone cyanohydrin is an aliphatic nitrile (general structure R-CN) compound with the hydroxyl group on the same carbon as the cyanyl group (Sunderman & Kincaid, 1953).
2) Derivatives include 2,2'-azobisisobutyronitrile; cyanazine; alpha, alpha-dimethyl-alpha-hydroxyacetophenone; methacrylamide sulphate; and trimethadione (Ashford, 1994).
3) Acetone cyanohydrin is available in technical grades of 97-98% purity (HSDB , 2000).
4) Acetone cyanohydrin readily decomposes to form hydrogen cyanide (Gosselin et al, 1984).

B)

1) Acetone cyanohydrin is an oxygen-containing liquid nitrile and is produced by "the condensation of acetone with hydrocyanic acid" (Lewis, 1998). It is the most important commercial cyanohydrin (HSDB , 2000).
2) Acetone cyanohydrin is prepared by the addition of acetone to sodium or potassium cyanide in water and treating with sulfuric acid below 20 degrees C. It is also formed by the reaction of acetone plus hydrogen cyanide (Ashford, 1994; Budavari, 1996).

C)

1) It is used in polymerization reactions, organic synthesis, especially methyl methacrylate, which is used in the formation of various plastics such as plexi-glas (ITI, 1995; Lewis, 1998).
2) Acetone cyanohydrin is also used as a reagent in aldehyde cyanohydrins formation (from aldehydes combined with a potassium cyanide-crown ether complex) and also as an effective stereoselective hydrocyanating reagent (HSDB , 2000).
3) It is used in the synthesis of foaming agents and in the manufacture of insecticides and pharmaceuticals (ITI, 1995; Lewis, 1998). It is used as a chemical intermediate and as a complexing agent for metals (Sittig, 1991; Snyder et al, 1990).
4) It is used in organic chemistry in transcyanohydrination preparation, such as 17-monocyanohydrin of 3, 17-diketo steroid "by hydrogen cyanide exchange with the reagent" (Budavari, 1996).
5) It is also used for transcyanohydrination reactions, such as in the preparation of a 17-monocyanohydrin form of a 3,7-diketo steroid by a hydrogen cyanide exchange with the reagent (Windholz et al, 1983).

Overview

Life Support

A)

Clinical Effects

0.2.1)

A) Acetone cyanohydrin produces its systemic toxicity by metabolically releasing CYANIDE after absorption.

1) It is a primary irritant of the eyes, skin, and respiratory tract.
2) Coma, seizures, dilated pupils, hypoventilation, cyanosis, pulmonary edema, palpitations, initial tachycardia and hypertension, hypotension, shock, nausea, vomiting, hepatotoxicity, kidney lesions, and metabolic acidosis may be noted.
3) Percutaneous absorption occurs.

0.2.4)

A) Eye irritation was observed.

0.2.5)

A) Palpitations or an irregular pulse may be noted. EKG changes may be seen in severe cyanide poisoning.

0.2.6)

A) Tachypnea and hyperpnea may be an early sign of toxicity. Hypoventilation progressing to apnea may be seen in the later phases of cyanide poisoning and is a major cause of death. Cyanosis is a late finding in cyanide poisoning and occurs after the apnea and circulatory collapse stages. Noncardiogenic pulmonary edema has been reported in acute cyanide poisoning. In rat experiments, respiratory tract irritation was noted.

0.2.7)

A) Headache, confusion, coma, seizures, CNS stimulation, paralysis and sequelae may be observed.

0.2.8)

A) Nausea and vomiting may be noted in mild poisoning or at an early stage.

0.2.11)

A) Elevated anion gap metabolic acidosis and elevated serum lactate levels are frequently found in cyanide poisoning.

0.2.14)

A) Mild dermal irritation may occur. Serious poisoning may be caused by percutaneous absorption.

0.2.20)

A) No data on the potential teratogenicity of acetone cyanohydrin were available. In animal experiments, related compounds did cause teratogenic effects.
B) At the time of this review, no reproductive studies were found for acetone cyanohydrin in humans or experimental animals.

0.2.21)

A) At the time of this review, no data on the potential carcinogenicity of acetone cyanohydrin were available.

0.2.22)

A) A bitter almond odor may be noted in patients poisoned by acetone cyanohydrin.

Laboratory Monitoring

A)

B)

Treatment Overview

0.4.2)

A) In symptomatic patients, skip these steps until other major emergency life support measures have been instituted.

1) Perform gastric lavage with a large bore tube after endotracheal intubation.
2) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.

a) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.

3) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.

B) The following treatments are those for SERIOUS POISONING BY ALL ROUTES OF EXPOSURE:
C) ADMINISTER 100% OXYGEN. Establish secure large bore IV.
D) A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to patients with symptomatic poisoning.
E) HYDROXOCOBALAMIN: ADULT DOSE: 5 g (two 2.5 g vials each reconstituted with 100 mL sterile 0.9% saline) administered as an intravenous infusion over 15 minutes. For severe poisoning, a second dose of 5 g may be infused intravenously over 15 minutes to 2 hours, depending on the patient's condition. CHILDREN: Limited experience; a dose of 70 mg/kg has been used in pediatric patients.
F) Prepare the CYANIDE ANTIDOTE KIT for use in SYMPTOMATIC PATIENTS.

1) SODIUM NITRITE: Adult: 10 mL (300 mg) of a 3% solution IV at a rate of 2.5 to 5 mL/minute; Child (with normal hemoglobin concentration): 0.2 mL/kg (6 mg/kg) of a 3% solution IV at a rate of 2.5 to 5 mL/minute, not to exceed 10 mL (300 mg).
2) Repeat one-half of initial sodium nitrite dose one-half hour later if there is inadequate clinical response. Calculate pediatric doses precisely to avoid potentially life-threatening methemoglobinemia. Use with caution if carbon monoxide poisoning is also suspected. Monitor blood pressure carefully. Reduce nitrite administration rate if hypotension occurs.
3) SODIUM THIOSULFATE: Administer sodium thiosulfate IV immediately following sodium nitrite. DOSE: ADULT: 50 mL (12.5 g) of a 25% solution; CHILD: 1 mL/kg (250 mg/kg) of a 25% solution, not to exceed 50 mL (12.5 g) total dose. A second dose, one-half of the first dose, may be administered if signs of cyanide toxicity reappear.

G) SODIUM BICARBONATE: Administer 1 mEq/kg IV to acidotic patients.
H) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).

1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.

I) METHEMOGLOBINEMIA

1) If excessive methemoglobinemia occurs, some authors have suggested that methylene blue should not be used because it could cause release of cyanide from the cyanmethemoglobin complex. Such authors have suggested that emergency exchange transfusion is the treatment of choice. Hyperbaric oxygen therapy could be used to support the patient while preparations for exchange transfusion are being made.
2) However, methylene or toluidine blue have been used successfully in this setting without worsening the course of the cyanide poisoning. There is some controversy over whether or not the induction of methemoglobinemia is the sodium nitrite mechanism of action in cyanide poisoning. As long as intensive care monitoring and further antidote doses (if required) are available, methylene blue can most likely be safely administered in this setting.
3) METHEMOGLOBINEMIA: Determine the methemoglobin concentration and evaluate the patient for clinical effects of methemoglobinemia (ie, dyspnea, headache, fatigue, CNS depression, tachycardia, metabolic acidosis). Treat patients with symptomatic methemoglobinemia with methylene blue (this usually occurs at methemoglobin concentrations above 20% to 30%, but may occur at lower methemoglobin concentrations in patients with anemia, or underlying pulmonary or cardiovascular disorders). Administer oxygen while preparing for methylene blue therapy.
4) METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg.
5) Concomitant use of methylene blue with serotonergic drugs, including serotonin reuptake inhibitors (SRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), triptans, and ergot alkaloids may increase the risk of potentially fatal serotonin syndrome.

J) HYPERBARIC OXYGEN AND HEMODIALYSIS: may be useful in severe cases not responsive to supportive and antidotal therapy.
K) HYPOTENSION: Infuse 10 to 20 mL/kg isotonic fluid. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (ADULT: begin infusion at 0.5 to 1 mcg/min; CHILD: begin infusion at 0.1 mcg/kg/min); titrate to desired response.
L) ACUTE LUNG INJURY: Maintain ventilation and oxygenation and evaluate with frequent arterial blood gases and/or pulse oximetry monitoring. Early use of PEEP and mechanical ventilation may be needed.

0.4.3)

A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
B) High concentrations of cyanide gas may cause a rapid loss of consciousness. Rescuers should wear self-contained positive pressure breathing apparatus to avoid contaminating themselves during rescue attempts.
C) Administer 100% humidified supplemental oxygen with assisted ventilation as required.

0.4.4)

A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.

0.4.5)

A) OVERVIEW

1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
2) Patients exposed dermally should be evaluated immediately to determine the extent of the exposure. If a severe exposure is suspected, observation and treatment as described in the ORAL and INHALATION sections should be followed.

Range Of Toxicity

A)

Clinical Effects

Summary Of Exposure

A)

1) It is a primary irritant of the eyes, skin, and respiratory tract.
2) Coma, seizures, dilated pupils, hypoventilation, cyanosis, pulmonary edema, palpitations, initial tachycardia and hypertension, hypotension, shock, nausea, vomiting, hepatotoxicity, kidney lesions, and metabolic acidosis may be noted.
3) Percutaneous absorption occurs.

Heent

3.4.1)

A) Eye irritation was observed.

3.4.3)

A) CONJUNCTIVITIS - Eye irritation was noted in rats exposed to acetone cyanohydrin vapor (Johannsen & Levinskas, 1986).
B) FUNDUSCOPIC EXAMINATION - Retinal arteries and veins that appear equally red on funduscopic examination suggest the diagnosis (Buchanan et al, 1976).

Cardiovascular

3.5.1)

A) Palpitations or an irregular pulse may be noted. EKG changes may be seen in severe cyanide poisoning.

3.5.2)

A) PALPITATIONS

1) Palpitations or an irregular pulse may be noted (EPA, 1985; (Sunderman & Kincaid, 1953).

B) ELECTROCARDIOGRAM ABNORMAL

1) Erratic atrial and ventricular cardiac rhythms with varying degrees of atrioventricular block followed by asystole may be seen in severe cyanide poisoning (Hall & Rumack, 1986). ST-T segment elevation or depression may be noted (Cope, 1961).

Respiratory

3.6.1)

A) Tachypnea and hyperpnea may be an early sign of toxicity. Hypoventilation progressing to apnea may be seen in the later phases of cyanide poisoning and is a major cause of death. Cyanosis is a late finding in cyanide poisoning and occurs after the apnea and circulatory collapse stages. Noncardiogenic pulmonary edema has been reported in acute cyanide poisoning. In rat experiments, respiratory tract irritation was noted.

3.6.2)

A) HYPERVENTILATION

1) An increased respiratory rate may be an early sign of toxicity (CHRIS , 1991). Part of the initial presentation of cyanide poisoning may be hyperpnea and tachypnea (Hall & Rumack, 1986).

B) HYPOVENTILATION

1) In the late stages of significant poisoning, slow and gasping respirations may develop (CHRIS , 1991). Cyanosis may be seen (ITI, 1985). Dyspnea was noted in exposed experimental animals (Willhite et al, 1981).

C) APNEA

1) Hypoventilation progressing to apnea may be seen in the later phases of cyanide poisoning and is a major cause of death (Vogel et al, 1981).

D) IRRITATION SYMPTOM

1) Respiratory tract irritation was noted in rats exposed to acetone cyanohydrin by inhalation (Johannsen & Levinskas, 1986).

E) ACUTE LUNG INJURY

1) Noncardiogenic pulmonary edema has been reported in cases of acute cyanide poisoning (Graham et al, 1977).

F) CYANOSIS

1) Cyanosis is a late finding in cyanide poisoning and does not occur until the stage of apnea and circulatory collapse (Hall & Rumack, 1986).

Neurologic

3.7.1)

A) Headache, confusion, coma, seizures, CNS stimulation, paralysis and sequelae may be observed.

3.7.2)

A) HEADACHE

1) Headache may be noted (CHRIS , 1991).

B) ALTERED MENTAL STATUS

1) Mental confusion, dizziness, ataxia, and weakness may be early signs of poisoning (CHRIS , 1991) ITI, 1985).

C) COMA

1) Coma can develop with significant exposure (ITI, 1985; (Thiess & Hey, 1969; Sunderman & Kincaid, 1953).

D) SEIZURE

1) Convulsions may be noted in significant poisonings (ITI, 1985; (Sunderman & Kincaid, 1953).

E) CENTRAL STIMULANT ADVERSE REACTION

1) CNS stimulation with varied presentations from anxiety to agitation and combative behavior may be seen in the early stages of cyanide poisoning (Vogel et al, 1981).

F) OPISTHOTONUS

1) Opisthotonos, trismus, and paralysis were reported in one case of cyanide poisoning (De Busk & Seidl, 1969).

G) SEQUELA

1) Most victims of acute cyanide poisoning either die acutely or fully recover, but rare cases of neurological sequelae such as personality changes, memory deficits, and extrapyramidal syndromes have been reported (Jouglard et al, 1971; Jouglard et al, 1974).

a) CASE REPORT - An 18-year-old patient who ingested between 975 and 1300 mg of potassium cyanide developed a Parkinsonian syndrome with rigidity and akinesis as a late sequelae (Uitti et al, 1985).

Gastrointestinal

3.8.1)

A) Nausea and vomiting may be noted in mild poisoning or at an early stage.

3.8.2)

A) NAUSEA AND VOMITING

1) Nausea and vomiting can be noted in mild or early poisonings (CHRIS , 1991) ITI, 1985; (Thiess & Hey, 1969; Sunderman & Kincaid, 1953).

Hepatic

3.9.2)

A) HEPATIC NECROSIS

1) Hepatic necrosis and fatty changes of the liver were noted in chronic ingestion experiments with rats (Clayton & Clayton, 1982; Johannsen & Levinskas, 1986). These effects have not been reported in exposed humans.

Genitourinary

3.10.2)

A) KIDNEY DISEASE

1) Kidney lesions were noted in chronic ingestion experiments with rats (Clayton & Clayton, 1982; Johannsen & Levinskas, 1986). These effects have not been reported in exposed humans.

Acid-Base

3.11.1)

A) Elevated anion gap metabolic acidosis and elevated serum lactate levels are frequently found in cyanide poisoning.

3.11.2)

A) ACIDOSIS

1) Elevated anion gap metabolic acidosis and elevated serum lactate levels are frequently found in cyanide poisoning (Hall & Rumack, 1986; Vogel et al, 1981).

Hematologic

3.13.2)

A) ERYTHROCYTOSIS

1) Increases in red blood cell counts, reticulocyte counts, and hemoglobin levels were noted in rats chronically fed acetone cyanohydrin (Johannsen & Levinskas, 1986). These effects have not been reported in exposed humans.

Dermatologic

3.14.1)

A) Mild dermal irritation may occur. Serious poisoning may be caused by percutaneous absorption.

3.14.2)

A) DERMATITIS

1) Mild dermal irritation may occur (NFPA, 1986; EPA, 1985).

B) SKIN ABSORPTION

1) Dermal absorption occurs and serious poisoning may be caused by this route of exposure (Thiess & Hey, 1969; Sunderman & Kincaid, 1953; Krefft, 1955).

Reproductive

3.20.1)

A) No data on the potential teratogenicity of acetone cyanohydrin were available. In animal experiments, related compounds did cause teratogenic effects.
B) At the time of this review, no reproductive studies were found for acetone cyanohydrin in humans or experimental animals.

3.20.2)

A) RELATED COMPOUNDS

1) Cyanide has been linked with congenital cretinism (deformities, dwarfism, and mental insufficiency) due to thyroid deficiency in regions of the world where iodine deficiency exists and cyanogenic cassava is a major part of the diet (Anon, 1972). The critical period is the first trimester; thyroid-related CNS damage can be prevented with iodine supplements (Anon, 1972).
2) ANIMAL STUDIES

a) Pregnant hamsters exposed by either inhalation of 5,000 to 8,000 ppm or given 100 to 400 mg/kg oral or intraperitoneal doses of acetonitrile delivered offspring with severe axial skeletal disorders (Willhite, 1983).

1) Injections of sodium thiosulfate antagonized the teratogenic effects (Willhite, 1983). Elevated cyanide and thiocyanate levels were found in all tissues studied 2.5 hours after oral or intraperitoneal dosing, and suggested that the in vivo liberation of cyanide from acetonitrile was responsible for the observed teratogenic effects (Willhite, 1983).

b) Laetrile given orally to pregnant hamsters produced skeletal malformations in the offspring and increased levels of tissue cyanide (Willhite, 1982). Intravenous administration of laetrile produced neither effect (Willhite, 1982).

1) Sodium thiosulfate administration protected the fetus from teratogenic effects (Willhite, 1982). These data suggested that the teratogenic effects were due to cyanide released in vivo from oral laetrile dosing (Willhite, 1982).

c) Rats fed cassava powder (containing high concentrations of a cyanogenic glycoside) as 50 to 80% of their diet during the first 5 days of pregnancy showed a low incidence of limb defects, open eye defects, microcephaly, and fetal growth retardation in fetuses collected on day 20 of pregnancy (Singh, 1981).
d) Intraperitoneal injections of acrylonitrile or propionitrile to hamsters on day 8 of gestation resulted in exencephaly, encephaloceles, and rib abnormalities in the offspring (Willhite et al, 1981).

1) Sodium thiosulfate injections protected the fetus from these effects, except at larger nitrile doses where thiosulfate protected the dam against overt poisoning but did not protect the fetus against malformations (Willhite et al, 1981). The teratogenic effects of both nitriles may be related to the metabolic release of cyanide after absorption (Willhite et al, 1981).

e) Sodium cyanide solution delivered by constant infusion to pregnant Golden Hamsters at doses from 0.126 to 0.1295 mmol/kg/hour between days 6 and 9 of gestation caused a high incidence of both resorptions and malformations in the offspring (Doherty et al, 1982).

1) Neural tube defects (exencephaly, encephalocele) were the most common malformations. Hydropericardium and crooked tails were also noted (Doherty et al, 1982).
2) Concomitant infusion of sodium thiosulfate prevented both maternal signs of toxicity and the teratogenic effects of the sodium cyanide infusion (Doherty et al, 1982).

f) Chemicals which liberate cyanide are known to be teratogenic in experimental animals, especially the aliphatic nitriles (Willhite et al, 1981; Smith, 1981), including acrylonitrile (Buchter & Peter, 1984) and acetonitrile (Willhite, 1983).

Carcinogenicity

3.21.1)

A) IARC Carcinogenicity Ratings for CAS75-86-5 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):

1) Not Listed

3.21.2)

A) At the time of this review, no data on the potential carcinogenicity of acetone cyanohydrin were available.

3.21.3)

A) LACK OF INFORMATION

1) At the time of this review, no data on the potential carcinogenicity of acetone cyanohydrin were available.

B) RELATED COMPOUNDS

1) Acrylonitrile has carcinogenic properties in some species of experimental animals and has been suggested to be associated with a slight increase in deaths from lung cancer and other malignancies in humans (Buchter & Peter, 1984; Geiger et al, 1983). Whether the metabolic release of cyanide after absorption plays any role in carcinogenesis is unknown. In isolated cell preparations, the release of cyanide does not appear to play a role in cell death (Geiger et al, 1983).

Genotoxicity

A)

Laboratory Monitoring

Monitoring Parameters Levels

4.1.1)

A) If respiratory tract irritation or respiratory depression is evident, monitor arterial blood gases, chest x-ray, and pulmonary function tests.
B) Determine hemoglobin, arterial blood gases, venous pO2 or measured venous %O2 saturation, electrolytes, serum lactate, and whole blood cyanide levels.

4.1.2)

A) BLOOD/SERUM CHEMISTRY

1) A number of chemicals produce abnormalities of the hematopoietic system, liver, and kidneys. Monitoring complete blood count and liver and kidney function tests is suggested for patients with significant exposure.
2) BLOOD CYANIDE LEVELS - Fatal blood cyanide levels after oral ingestion

a) Ballantyne et al (1974) reported 34 cases:

AVERAGE LEVEL	RANGE
12.4 mg/L (mcg/mL)	1.1 to 53.1 mg/L (mcg/mL)
(1.2 mg%)	(0.1 to 5.3 mg%)
(SI = 476.9 mcmol/L)	(SI = 42.3 to 2042 mcmol/L)

b) Rehlung (1967) reported 32 cases:

AVERAGE LEVEL	RANGE
36.5 mg/L (mcg/mL)	0.4 to 230 mg/L (mcg/mL)
(3.7 mg%)	(0.04 to 23 mg%)
(SI = 1403.8 mcmol/L)	(SI = 15.4 to 8846 mcmol/L)

3) Blood cyanide levels and associated symptoms (Graham et al, 1977)

a) No symptoms: less than 0.2 mg/L (mcg/mL)

1) (0.02 mg%)
2) (SI = 7.7 mcmol/L)

b) Flushing and tachycardia: 0.5-1.0 mg/L (mcg/mL)

1) (0.05-0.1 mg%)
2) (SI = 19.2 to 38.5 mcmol/L)

c) Obtundation: 1.0-2.5 mg/L (mcg/mL)

1) (0.1-0.25 mg%)
2) (SI = 38.5 to 96.1 mcmol/L)

d) Coma and respiratory depression: greater than

1) 2.5 mg/L (mcg/mL)
2) (0.25 mg%)
3) (SI = 96.1 mcmol/L)

e) Death: greater than 3 mg/L (mcg/mL)

1) 0.3 mg%
2) (SI = 115.4 mcmol/L)

4) Blood cyanide levels associated with smoking (Clark et al, 1981)

a) Smokers: up to 0.5 mg/L (mcg/mL)

1) (SI = 19.2 mcmol/L)

5) Blood cyanide levels in smoke inhalation victims:

a) (Hart et al, 1985)

Patient 1	3.9 mcg/mL	expired
Patient 2	1.8 mcg/mL	survived
Patient 3	0.35 mcg/mL	survived
Patient 4	0.42 mcg/mL	survived
Patient 5	1.65 mcg/mL	survived

b) (Jones et al, 1987)

Case 1	1.8 mcg/mL	expired
Case 2	2.4 mcg/mL	expired
Case 3	1.4 mcg/mL	expired
Case 4	1.5 mcg/mL	expired

B) OTHER

1) Arterial blood gases and serum electrolytes are useful in the assessment of potential elevated anion gap metabolic acidosis in patients poisoned with cyanide (Hall & Rumack, 1986; Vogel et al, 1981).
2) A "% O2 SATURATION GAP" may exist with decreased MEASURED and normal CALCULATED arterial %O2 saturation values due to the propensity for some cyanide to form cyanhemoglobin which will not bind or transport oxygen (Hall & Rumack, 1986).
3) A REDUCED ARTERIO-CENTRAL VENOUS MEASURED %O2 SATURATION DIFFERENCE may be seen due to cellular inability to extract oxygen (Graham et al, 1977; Paulet, 1955).
4) Serum lactate levels may be useful in monitoring the severity of poisoning and the efficacy of treatment (Vogel et al, 1981).
5) Monitor methemoglobin levels during nitrite administration, especially if more than one dose is needed. Maintain methemoglobin levels below 30% (Hall & Rumack, 1986).

4.1.3)

A) URINARY LEVELS

1) Cyanide and thiocyanate levels can also be measured in timed urine collections which may yield useful information on cyanide clearance.

4.1.4)

A) OTHER

1) MONITORING

a) If respiratory tract irritation is present, monitor arterial blood gases and chest x-ray.

Radiographic Studies

A)

1) Patients with respiratory distress should have a chest x-ray.

Methods

A)

1) Cyanide can be measured chemically by several methods but there is no time to perform this procedure; initial therapy should be based on clinical examination.
2) BIOLOGICAL SPECIMENS - Cyanide can be liberated from biological specimens by acidification, followed by absorption in alkali and interaction with chromophoric reagents for quantification by absorbance spectroscopy (HSDB, 1990).
3) BIOLOGICAL SPECIMENS - Cyanide can also be measured in biological fluids by gas chromatography following conversion to cyanogen chloride by reaction with chloramine-T (HSDB, 1990).
4) BIOLOGICAL SPECIMENS - An ion-specific electrode method has sometimes been used for measuring cyanide in biological specimens (Bismuth et al, 1984).
5) BIOLOGICAL SPECIMENS - A fluorometric diffusion method based on detection of fluorescing p-benzoquinone derivatives can be used to determine cyanide in biological fluids (HSDB, 1990).
6) BIOLOGICAL SPECIMENS - An automated microdistillation assay technique has been developed that can provide whole blood and plasma cyanide levels in less than one-half hour (Groff et al, 1985) but is not yet generally available.

Treatment

Life Support

A)

Patient Disposition

6.3.1)

6.3.1.1) ADMISSION CRITERIA/ORAL

A) All patients with acetone cyanohydrin exposure resulting in symptoms should be admitted to the hospital. Whenever the cyanide antidote kit is used, the patient should be admitted to the intensive care unit.

6.3.1.5) OBSERVATION CRITERIA/ORAL

A) Patients with a history of significant acetone cyanohydrin exposure but who are asymptomatic should be observed closely in the hospital with an IV in place and the drugs drawn up ready at the bedside.

1) Exposure to some nitrile compounds has resulted in delayed onset of toxicity (from 1 or 2 hours to greater than 12 hours in some cases) (Amdur, 1959; Dequidt et al, 1974). Patients exposed to acetone cyanohydrin should most likely be observed in a controlled setting for at least 12 hours.

Monitoring

A)

B)

Oral Exposure

6.5.2)

A) SUMMARY

1) EMERGENCY MEASURES: In symptomatic patients, skip these steps until other major emergency measures including use of cyanide antidote kit and other life support measures have been instituted.

B) GASTRIC LAVAGE

1) Perform gastric lavage with a large bore tube after endotracheal intubation. Because of the rapid progression of the clinical course and potential for early development of seizures, coma, or apnea, inducing vomiting, may result in a significant delay in the removal of gastric contents and an unacceptable risk of aspiration of gastric contents.
2) INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes).

a) Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.

3) PRECAUTIONS:

a) SEIZURE CONTROL: Is mandatory prior to gastric lavage.
b) AIRWAY PROTECTION: Place patients in the head down left lateral decubitus position, with suction available. Patients with depressed mental status should be intubated with a cuffed endotracheal tube prior to lavage.

4) LAVAGE FLUID:

a) Use small aliquots of liquid. Lavage with 200 to 300 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in older children or adults) and 10 milliliters/kilogram body weight of normal saline in young children(Vale et al, 2004) and repeat until lavage return is clear.
b) The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
c) CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.

5) COMPLICATIONS:

a) Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications (Caravati et al, 2001).
b) Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).

6) CONTRAINDICATIONS:

a) Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.

C) ACTIVATED CHARCOAL

1) CHARCOAL ADMINISTRATION

a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.

2) CHARCOAL DOSE

a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).

1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).

b) ADVERSE EFFECTS/CONTRAINDICATIONS

1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).

6.5.3)

A) OXYGEN

1) Administer 100% oxygen to maintain an elevated PO2. Oxygen may reverse the cyanide-cytochrome oxidase complex and facilitate the conversion to thiocyanate following thiosulfate administration (Graham et al, 1977). There is fairly good evidence that 100% oxygen, combined with traditional nitrite/thiosulfate therapy is better than nitrite/thiosulfate alone (Litovitz et al, 1983; Way et al, 1972).
2) HYPERBARIC OXYGEN (HBO) THERAPY - is approved for cyanide poisoning as a category one condition (approved for third party reimbursement and known effective as treatment) by the Undersea Medical Society (Myers & Schnitzer, 1984). Hyperbaric oxygen has been suggested to improve clinical outcome, especially in those patients with CNS toxicity not responding to more traditional therapy. Animal studies have both confirmed and refuted this (Skene et al, 1966; Way et al, 1972; Takano et al, 1980).

a) Case reports suggest that HBO may be of value (Carden, 1970; Trapp, 1970). However, one patient treated with supportive therapy, antidotes, and HBO did not survive a serious poisoning (Litovitz et al, 1983).
b) Hyperbaric oxygen should be reserved for those patients with significant symptoms (ie, coma, seizures) who do not respond to normal supportive and antidotal therapy, and for those patients poisoned by both cyanide and carbon monoxide secondary to smoke inhalation (Hart et al, 1985).

B) CYANIDE ANTIDOTE

1) IV ACCESS: Establish secure large bore IV line.
2) A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to patients with symptomatic poisoning.
3) HYDROXOCOBALAMIN - CYANOKIT(R)

a) ADULT DOSE: 5 g (two 2.5 g vials each reconstituted with 100 mL sterile 0.9% saline) administered as an intravenous infusion over 15 minutes. For severe poisoning, a second dose of 5 g may be infused intravenously over 15 minutes to 2 hours, depending on the patient's condition (Prod Info CYANOKIT(R) 2.5g IV injection, 2006).
b) PEDIATRIC DOSE: A dose of 70 mg/kg has been used in pediatric patients, based on limited post-marketing experience outside the US (Prod Info CYANOKIT(R) 2.5g IV injection, 2006).
c) INDICATIONS: Known or suspected cyanide poisoning.
d) ADVERSE EFFECTS: Transient hypertension, allergic reactions (including anaphylaxis), nausea, headache, rash. Hydroxocobalamin's deep red color causes red-colored urine in all patients, and erythema of the skin in most (Prod Info CYANOKIT(R) 2.5g IV injection, 2006).
e) LABORATORY INTERFERENCE: Because of its' color, hydroxocobalamin interferes with colorimetric determination of various laboratory parameters. It may artificially increase serum creatinine, bilirubin, triglycerides, cholesterol, total protein, glucose, albumin , alkaline phosphatase and hemoglobin. It may artificially decrease serum ALT and amylase. It may artificially increase urinary pH, glucose, protein, erythrocytes, leukocytes, ketones, bilirubin, urobilinogen, and nitrate (Prod Info CYANOKIT(R) 2.5g IV injection, 2006).
f) HEMODIALYSIS INTERFERENCE: Dialysis machines have a spectrophotometric safety measure that can shut down after detecting blood leaking across the dialysis membrane. Hydroxocobalamin has a deep red color and can permeate the dialysis membrane, coloring the dialysate and causing the hemodialysis machine to shut down erroneously. In one case report, a patient with cyanide poisoning underwent dialysis after receiving 5 g of IV hydroxocobalamin because of refractory acidemia, reduced kidney function and hyperkalemia. A blood leak alarm caused the dialysis machine to shut down erroneously, delaying therapy, and resulting in the death of the patient (Stellpflug et al, 2013).

4) CYANIDE ANTIDOTE KIT

a) OBTAIN AND PREPARE for administration a CYANIDE ANTIDOTE KIT, consisting of sodium nitrite and sodium thiosulfate.
b) Antidotes should be administered in patients who are clinically symptomatic (i.e., unstable vital signs, acidosis, impaired consciousness, seizures, or coma).
c) SODIUM NITRITE

1) INDICATION

a) Sodium nitrite should be given initially and administered as soon as vascular access is established.
b) Further administration of sodium nitrite is dictated only by the clinical situation, provided no significant complications (hypotension, excessive methemoglobinemia) are present. Use with caution if carbon monoxide poisoning is also suspected.
c) The goal of nitrite therapy is to achieve a methemoglobin level of 20% to 30%. This level is not based on clinical data, but represents the tolerated concentration without significant adverse symptoms from methemoglobin in an otherwise healthy individual. Clinical response has been reported to occur with methemoglobin levels in the range of 3.6% to 9.2% (DiNapoli et al, 1989; Johnson et al, 1989; Johnson & Mellors, 1988).

2) ADULT DOSE

a) 10 mL of a 3% solution (300 mg) administered intravenously at a rate of 2.5 to 5 mL/minute (Prod Info NITHIODOTE intravenous injection solution, 2011). Frequent blood pressure monitoring must accompany sodium nitrite injection and the rate slowed if hypotension occurs.
b) If there is inadequate clinical response, an additional dose of sodium nitrite at half the amount of the initial dose may be administered 30 minutes following the first dose (Prod Info NITHIODOTE intravenous injection solution, 2011).

3) PEDIATRIC DOSE

a) The recommended pediatric sodium nitrite dose is 0.2 mL/kg of a 3% solution (6 mg/kg) administered intravenously at a rate of 2.5 to 5 mL/minute, not to exceed 10 mL (300 mg) (Prod Info NITHIODOTE intravenous injection solution, 2011).
b) If there is inadequate clinical response, an additional dose of sodium nitrite at half the amount of the initial dose may be administered 30 minutes following the first dose (Prod Info NITHIODOTE intravenous injection solution, 2011; Berlin, 1970a).
c) PRESENCE OF ANEMIA: If there is a reason to suspect the presence of anemia, the following initial sodium nitrite doses should be given, depending on the child's hemoglobin (sodium nitrite should not exceed the doses listed below; fatal methemoglobinemia may result) (Berlin, 1970a):

1) Hemoglobin: 8 g/dL - Initial 3% sodium nitrite dose: 0.22 mL/kg (6.6 mg/kg)
2) Hemoglobin: 10 g/dL - Initial 3% sodium nitrite dose: 0.27 mL/kg (8.7 mg/kg)
3) Hemoglobin: 12 g/dL (average child) - Initial 3% sodium nitrite dose: 0.33 mL/kg (10 mg/kg)
4) Hemoglobin: 14 g/dL - Initial 3% sodium nitrite dose: 0.39 mL/kg (11.6 mg/kg)

4) It is highly recommended that total hemoglobin and methemoglobin concentrations be rapidly measured (30 minutes after dose), when possible, before repeating a dose of sodium nitrite to be sure that dangerous methemoglobinemia will not occur, especially in the pediatric patient.
5) Monitor blood pressure frequently and treat hypotension by slowing infusion rate and giving crystalloids and vasopressors. Consider possible excessive methemoglobin formation if patient deteriorates during therapy.
6) Excessive methemoglobinemia and hypotension are potential complications of nitrite therapy.
7) In individuals with G6PD deficiency, therapy with methemoglobin-inducing agents is contraindicated because of the likelihood of serious hemolysis.

d) SODIUM THIOSULFATE

1) Sodium thiosulfate is the second component of the cyanide antidote kit. It is supplied as 50 mL of a 25% solution and it is administered intravenously. There are no adverse reactions to thiosulfate itself. The pediatric dose is adjusted for weight and not hemoglobin concentration.
2) Sodium thiosulfate supplies sulfur for the rhodanese reaction, and is recommended after sodium nitrite, hydroxocobalamin, or 4-DMAP (4-dimethylaminophenol) administration (Marrs, 1988; Hall & Rumack, 1987).
3) DOSE

a) Follow sodium nitrite with IV sodium thiosulfate. ADULT: Administer 50 mL (12.5 g) of a 25% solution IV; PEDIATRIC: 1 mL/kg of a 25% solution (250 mg/kg), not to exceed 50 mL (12.5 g) total dose (Prod Info NITHIODOTE intravenous injection solution, 2011).
b) A second dose, one-half of the first dose, may be administered if signs of cyanide toxicity reappear (Prod Info NITHIODOTE intravenous injection solution, 2011).
c) Sodium thiosulfate is usually used in combination with sodium nitrite but may be used alone (Prod Info sodium thiosulfate IV injection, 2003).
d) Sodium thiosulfate can be administered without sodium nitrite in patients at risk to develop further methemoglobinemia (ie excessive methemoglobinemia or hypotension after initial sodium nitrite administration or in the presence of methemoglobinemia or carboxyhemoglobin in patients with smoke inhalation due to fire). Sodium thiosulfate can also be used in combination with hydroxocobalamin to treat cyanide poisoning (Howland, 2011)
e) CONTINUOUS INFUSION: It has been suggested that a continuous infusion of sodium thiosulfate be given after the initial bolus to maintain high thiosulfate levels. Low sodium intravenous fluids are required to avoid sodium overload. If large amounts of sodium thiosulfate are required, hemodialysis may be necessary to maintain a physiologic serum sodium level (Turchen et al, 1991).
f) ADVERSE EVENTS: Sodium thiosulfate does not usually produce significant toxicity. Possible adverse events include hypotension, headache, nausea, vomiting, disorientation, and prolonged bleeding time (Prod Info NITHIODOTE intravenous injection solution, 2011).

C) ACIDOSIS

1) Administer sodium bicarbonate, 1 mEq/kg intravenously to acidotic patients. Base further sodium bicarbonate administration on serial arterial blood gas determinations.

D) MONITORING OF PATIENT

1) Obtain blood for arterial blood gases (ABGS), electrolytes, serum lactate, and whole blood cyanide.
2) INTERPRETATION OF LABORATORY VALUES

a) The following set of laboratory values suggest poisoning with an agent that inhibits oxidative phosphorylation (ie, cyanide, hydrogen sulfide, carbon monoxide) (Hall & Rumack, 1986).
b) Arterial pO2 - Usually normal until the stage of apnea. Usually remains normal until terminal stages of the poisoning if supplemental oxygen and assisted ventilation are provided.
c) Serum electrolytes - Elevated anion gap (Na - (Cl + CO2)) (normals 12 to 16 mEq/L (12 to 16 mmol/L) or less) is present from the presence of unmeasured organic anions (usually lactate).
d) Serum Lactate - Elevated (normals 0.6 to 1.8 mEq/L) (0.6 to 1.8 mmol/L) due to anaerobic metabolism with excessive production of lactic acid.

E) SEIZURE

1) SUMMARY

a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).

2) DIAZEPAM

a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .

3) NO INTRAVENOUS ACCESS

a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).

4) LORAZEPAM

a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).

5) PHENOBARBITAL

a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).

6) OTHER AGENTS

a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):

1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).

F) METHEMOGLOBINEMIA

1) While clinically significant excessive methemoglobinemia has occurred following sodium nitrite therapy for cyanide poisoning, such instances are rare and usually occur only in children receiving excessive nitrite doses.
2) If excessive methemoglobinemia occurs, some authors have suggested that methylene blue should not be used because it could cause release of cyanide from the cyanmethemoglobin complex. Such authors have suggested that emergency exchange transfusion is the treatment of choice (Berlin, 1970). Hyperbaric oxygen therapy could be used to support the patient while preparations for exchange transfusion are being made.
3) However, methylene or toluidine blue have been used successfully in this setting without worsening the course of the cyanide poisoning (van Heijst et al, 1987). There is some controversy over whether or not the induction of methemoglobinemia is the sodium nitrite mechanism of action in cyanide poisoning. As long as intensive care monitoring and further antidote doses (if required) are available, methylene blue can most likely be safely administered in this setting.
4) SUMMARY

a) Determine the methemoglobin concentration and evaluate the patient for clinical effects of methemoglobinemia (ie, dyspnea, headache, fatigue, CNS depression, tachycardia, metabolic acidosis). Treat patients with symptomatic methemoglobinemia with methylene blue (this usually occurs at methemoglobin concentrations above 20% to 30%, but may occur at lower methemoglobin concentrations in patients with anemia, or underlying pulmonary or cardiovascular disorders). Administer oxygen while preparing for methylene blue therapy.

5) METHYLENE BLUE

a) INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules (Prod Info PROVAYBLUE(TM) intravenous injection, 2016) and 10 mg/1 mL (1% solution) vials (Prod Info methylene blue 1% intravenous injection, 2011). REPEAT DOSES: Additional doses may be required, especially for substances with prolonged absorption, slow elimination, or those that form metabolites that produce methemoglobin. NOTE: Large doses of methylene blue may cause methemoglobinemia or hemolysis (Howland, 2006). Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection (Prod Info methylene blue 1% intravenous injection, 2011; Herman et al, 1999). NEONATES: DOSE: 0.3 to 1 mg/kg (Hjelt et al, 1995).
b) CONTRAINDICATIONS: G-6-PD deficiency (methylene blue may cause hemolysis), known hypersensitivity to methylene blue, methemoglobin reductase deficiency (Shepherd & Keyes, 2004)
c) FAILURE: Failure of methylene blue therapy suggests: inadequate dose of methylene blue, inadequate decontamination, NADPH dependent methemoglobin reductase deficiency, hemoglobin M disease, sulfhemoglobinemia, or G-6-PD deficiency. Methylene blue is reduced by methemoglobin reductase and nicotinamide adenosine dinucleotide phosphate (NADPH) to leukomethylene blue. This in turn reduces methemoglobin. Red blood cells of patients with G-6-PD deficiency do not produce enough NADPH to convert methylene blue to leukomethylene blue (do Nascimento et al, 2008).
d) DRUG INTERACTION: Concomitant use of methylene blue with serotonergic drugs, including serotonin reuptake inhibitors (SRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), triptans, and ergot alkaloids may increase the risk of potentially fatal serotonin syndrome (U.S. Food and Drug Administration, 2011; Stanford et al, 2010; Prod Info methylene blue 1% IV injection, 2011).

6) TOLUIDINE BLUE OR TOLONIUM CHLORIDE (GERMANY)

a) DOSE: 2 to 4 mg/kg intravenously over 5 minutes. Dose may be repeated in 30 minutes (Nemec, 2011; Lindenmann et al, 2006; Kiese et al, 1972).
b) SIDE EFFECTS: Hypotension with rapid intravenous administration. Vomiting, diarrhea, excessive sweating, hypotension, dysrhythmias, hemolysis, agranulocytosis and acute renal insufficiency after overdose (Dunipace et al, 1992; Hix & Wilson, 1987; Winek et al, 1969; Teunis et al, 1970; Marquez & Todd, 1959).
c) CONTRAINDICATIONS: G-6-PD deficiency; may cause hemolysis.

G) EXPERIMENTAL THERAPY

1) DICOBALT-EDTA

a) Kelocyanor(R) is a highly effective cyanide chelating agent currently used in Europe and Australia. Significant toxicity from the antidote (severe hypertension or hypotension, cardiac ischemia or arrhythmias) may be seen in patients incorrectly diagnosed as being poisoned by cyanide and administered this antidote (Pronczuk de Garbino & Bismuth, 1981). Severe anaphylactoid reactions with airway compromise may also occur (Dodds & McKnight, 1985). Dicobalt-EDTA is not available in America.

2) 4-DIMETHYLAMINOPHENOL

a) 4-DMAP is a methemoglobin inducing agent used in some European countries for the treatment of acute cyanide poisoning. Excessive methemoglobinemia may be a major complication following the use of this agent (van Dijk et al, 1986).

3) STROMA-FREE METHEMOGLOBIN SOLUTION

a) Stroma-free methemoglobin solution prepared from outdated human red blood cells by oxidation of the ferrous iron of hemoglobin to the ferric form in vitro has been studied in experimental animals and shows promise as a cyanide antidote (Ten Eyck et al, 1985). It has not been studied in human poisoning cases and is not available for human administration.

4) ALPHA-KETOGLUTARIC ACID

a) Alpha-ketoglutaric acid is also being tested as a replacement for sodium nitrite in combination with sodium thiosulfate in animal models where it has been efficacious in experimental cyanide poisoning (Moore et al, 1986). It has not been studied in human poisoning cases and is not available for human administration.

5) CHLORPROMAZINE

a) Chlorpromazine has been studied in various animal models as a possible cyanide antidote. Conflicting reports of efficacy have been published (Pettersen & Cohen, 1986). It has not been studied in human poisoning cases.

H) HYPOTENSIVE EPISODE

1) SUMMARY

a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.

2) DOPAMINE

a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).

3) NOREPINEPHRINE

a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
b) DOSE

1) ADULT: Dose range: 0.1 to 0.5 microgram/kilogram/minute (eg, 70 kg adult 7 to 35 mcg/min); titrate to maintain adequate blood pressure (Peberdy et al, 2010).
2) CHILD: Dose range: 0.1 to 2 micrograms/kilogram/minute; titrate to maintain adequate blood pressure (Kleinman et al, 2010).
3) CAUTION: Extravasation may cause local tissue ischemia, administration by central venous catheter is advised (Peberdy et al, 2010).

I) ACUTE LUNG INJURY

1) ONSET: Onset of acute lung injury after toxic exposure may be delayed up to 24 to 72 hours after exposure in some cases.
2) NON-PHARMACOLOGIC TREATMENT: The treatment of acute lung injury is primarily supportive (Cataletto, 2012). Maintain adequate ventilation and oxygenation with frequent monitoring of arterial blood gases and/or pulse oximetry. If a high FIO2 is required to maintain adequate oxygenation, mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required; ventilation with small tidal volumes (6 mL/kg) is preferred if ARDS develops (Haas, 2011; Stolbach & Hoffman, 2011).

a) To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Use of smaller tidal volumes (6 mL/kg) and lower plateau pressures (30 cm water or less) has been associated with decreased mortality and more rapid weaning from mechanical ventilation in patients with ARDS (Brower et al, 2000). More treatment information may be obtained from ARDS Clinical Network website, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary, http://www.ardsnet.org/node/77791 (NHLBI ARDS Network, 2008)

3) FLUIDS: Crystalloid solutions must be administered judiciously. Pulmonary artery monitoring may help. In general the pulmonary artery wedge pressure should be kept relatively low while still maintaining adequate cardiac output, blood pressure and urine output (Stolbach & Hoffman, 2011).
4) ANTIBIOTICS: Indicated only when there is evidence of infection (Artigas et al, 1998).
5) EXPERIMENTAL THERAPY: Partial liquid ventilation has shown promise in preliminary studies (Kollef & Schuster, 1995).
6) CALFACTANT: In a multicenter, randomized, blinded trial, endotracheal instillation of 2 doses of 80 mL/m(2) calfactant (35 mg/mL of phospholipid suspension in saline) in infants, children, and adolescents with acute lung injury resulted in acute improvement in oxygenation and lower mortality; however, no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was noted. Adverse effects (transient hypoxia and hypotension) were more frequent in calfactant patients, but these effects were mild and did not require withdrawal from the study (Wilson et al, 2005).
7) However, in a multicenter, randomized, controlled, and masked trial, endotracheal instillation of up to 3 doses of calfactant (30 mg) in adults only with acute lung injury/ARDS due to direct lung injury was not associated with improved oxygenation and longer term benefits compared to the placebo group. It was also associated with significant increases in hypoxia and hypotension (Willson et al, 2015).

J) HOSPITAL ADMISSION

1) All patients with acetone cyanohydrin exposure resulting in symptoms should be admitted to the hospital. Whenever the cyanide antidote kit is used, the patient should be admitted to the intensive care unit.

K) OBSERVATION REGIMES

1) Patients with a history of significant acetone cyanohydrin exposure but who are asymptomatic should be observed closely in the hospital with an IV in place and the drugs drawn up ready at the bedside.

a) Exposure to some nitrile compounds has resulted in delayed onset of toxicity (from 1 or 2 hours to greater than 12 hours in some cases) (Amdur, 1959; Dequidt et al, 1974). Patients exposed to acetone cyanohydrin should most likely be observed in a controlled setting for at least 12 hours.

Inhalation Exposure

6.7.1)

A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.
D) High concentrations of cyanide gas may cause a rapid loss of consciousness (Peden et al, 1986). Rescuers should wear self-contained positive pressure breathing apparatus to avoid contaminating themselves during rescue attempts (NFPA, 1986).

6.7.2)

A) OXYGEN

1) Administer 100% humidified supplemental oxygen with assisted ventilation as required.

B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

6.8.1)

A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).

Dermal Exposure

6.9.1)

A) DERMAL DECONTAMINATION

1) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

6.9.2)

A) SKIN ABSORPTION

1) Some chemicals can produce systemic poisoning by absorption through intact skin. Carefully observe patients with dermal exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.

B) SUPPORT

1) Patients exposed dermally should be evaluated immediately to determine the extent of the exposure. If a severe exposure is suspected, observation and treatment as described in the ORAL EXPOSURE section should be followed.

C) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Enhanced Elimination

A)

1) May be an effective adjunct by correcting resistant acidemia and by increasing thiocyanate clearance, thereby favoring thiosulfate-cyanide reaction to thiocyanate (Wesson et al, 1985).

a) It has, however, been used in only one reported case, and antidote therapy with sodium nitrite and sodium thiosulfate was also administered (Wesson et al, 1985).
b) Limited animal studies, using historical controls and only a few animals, have so far shown some potential effectiveness when combined with thiosulfate infusion (Gonzales & Sabatini, 1989).
c) Hemodialysis cannot be considered standard therapy for cyanide poisoning at this time.

B)

1) Charcoal hemoperfusion has also been used in one reported case of cyanide poisoning (Krieg & Saxena, 1987).

a) This patient also received supportive measures and sodium nitrite/thiosulfate antidotes.
b) The outcome in this case was no different than that of other patients treated similarly without hemoperfusion.
c) Hemoperfusion cannot be considered standard therapy for cyanide poisoning at this time.

Abstracts

Case Reports

A)

1) DERMAL

a) Thiess & Hey (1969) described a case of acetone cyanohydrin poisoning in a worker who was unloading the material from a tank car into a drum, and was exposed mainly by the dermal route. Nausea, vomiting, and coma developed.

1) Treatment with sodium nitrite and sodium thiosulfate resulted in full recovery. The patient left the hospital after 3 days and returned to work 8 days after the accident.

b) A worker had dermal exposure to the material. About 3 hours later, nausea developed. Convulsions and coma developed about 5 hours after exposure. The patient died 6.5 hours after exposure, but apparently did not receive treatment with specific cyanide antidotes (Sunderman & Kincaid, 1953).
c) A worker had acetone cyanohydrin spilled on the skin and face. Vomiting, generalized convulsions, coma, and hypoventilation developed within 10 minutes after the accident. The patient later died despite receiving supportive treatment but apparently no specific cyanide antidotes (Krefft, 1955).
d) A 45-year-old male was dermally exposed to acetone cyanohydrin while repairing a supply line at a chemical plant.

1) He began to experience dizziness half an hour after exposure, followed by coarse tremors and shortness of breath enroute to the hospital.
2) He was found to have elevated anion gap metabolic acidosis upon admission.
3) Treatment, at approximately 2.5 hours post exposure, included administration of 300 mg sodium nitrite and 12.5 grams sodium thiosulfate.
4) Further administration of sodium nitrite (300 mg and 150 mg respectively) was instituted to counter methemoglobin levels of 4.5 and 8.0%. The patient recovered fully (Winter et al, 1989).

2) ORAL

a) A worker drank some alcohol contaminated with acetone cyanohydrin. The patient was found unconscious and received treatment with sodium nitrite and sodium thiosulfate. Although the patient regained consciousness for a short period, he died about 12 hours after admission to the hospital (Sunderman & Kincaid, 1953).

3) INHALATION

a) Two workers had inhalation exposure after the material was accidentally spilled into the room. The condensed material contained about 20 percent hydrocyanic acid. About 15 minutes after the spill, both workers were found unconscious. One patient later died, but the other recovered fully (Krefft, 1955).

Range Of Toxicity

Summary

A)

Minimum Lethal Exposure

A)

1) "Oral ingestion of an unknown amount of acetone cyanohydrin caused death 12H post exposure" (Snyder et al, 1990).
2) When a tank overflowed, a worker was splashed with an unknown quantity of acetone cyanohydrin. "After 3 hr he complained of nausea and was examined at a hospital but returned to work on the advice of a physician. At work he became nauseated again, lost consciousness, and became convulsive. He died 6.5 hr after the initial exposure" (Clayton & Clayton, 1994).

B)

1) Rats exposed to a saturated atmosphere of acetone cyanohydrin all died within 1 to 2 minutes (Sunderman & Kincaid, 1953). When the acetone cyanohydrin was treated to remove essentially all traces of hydrogen cyanide, the LC50 occurred in saturated air in approximately 10 minutes in rats (Sunderman & Kincaid, 1953).

Maximum Tolerated Exposure

A)

1) The maximum tolerated human exposure to this agent has not been delineated.

Workplace Standards

A)

1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.

a) Adopted Value

1) Acetone cyanohydrin, as CN

a) TLV:

1) TLV-TWA:
2) TLV-STEL:
3) TLV-Ceiling: 5 mg/m(3)

b) Notations and Endnotes:

1) Carcinogenicity Category: Not Listed
2) Codes: Skin
3) Definitions:

a) Skin: This refers to the potential significant contribution to the overall exposure by the cutaneous route, including mucous membranes and the eyes, either by contact with vapors or, of likely greater significance, by direct skin contact with the substance. It should be noted that although some materials are capable of causing irritation, dermatitis, and sensitization in workers, these properties are not considered relevant when assigning a skin notation. Rather, data from acute dermal studies and repeated dose dermal studies in animals or humans, along with the ability of the chemical to be absorbed, are integrated in the decision-making toward assignment of the skin designation. Use of the skin designation provides an alert that air sampling would not be sufficient by itself in quantifying exposure from the substance and that measures to prevent significant cutaneous absorption may be warranted. Please see "Definitions and Notations" (in TLV booklet) for full definition.

c) TLV Basis - Critical Effect(s): URT irr; headache; hypoxia/cyanosis
d) Molecular Weight: 85.1

1) For gases and vapors, to convert the TLV from ppm to mg/m(3):

a) [(TLV in ppm)(gram molecular weight of substance)]/24.45

2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:

a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance

e) Additional information:

B) NIOSH REL and IDLH Values for CAS75-86-5 (National Institute for Occupational Safety and Health, 2007):

1) Listed as: Acetone cyanohydrin
2) REL:

a) TWA:
b) STEL:
c) Ceiling: 1 ppm (4 mg/m(3)) [15-minute]
d) Carcinogen Listing: (Not Listed) Not Listed
e) Skin Designation: Not Listed
f) Note(s):

3) IDLH: Not Listed

C) Carcinogenicity Ratings for CAS75-86-5 :

1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed ; Listed as: Acetone cyanohydrin, as CN
2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: Acetone cyanohydrin
5) MAK (DFG, 2002): Not Listed
6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

D) OSHA PEL Values for CAS75-86-5 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):

1) Not Listed

Toxicity Information

7.7.1)

A) References: Budavari, 1996 Clayton & Clayton, 1994 HSDB, 2000 ITI, 1995 Lewis, 1996 OHM/TADS, 2000 RTECS, 2000

1) LD50- (INTRAPERITONEAL)MOUSE:

a) 1 mg/kg (RTECS, 2000)

2) LD50- (ORAL)MOUSE:

a) 14 mg/kg (Lewis, 1996)
b) 15 mg/kg (HSDB, 2000)
c) 1898 mcg/kg (RTECS, 2000)
d) 3 mg/kg (ITI, 1995)
e) 2.9 mg/kg (OHM/TADS, 2000)

3) LD50- (ORAL)RAT:

a) 19,300 mcg/kg
b) 18,650 mcg/kg
c) 0.17 g/kg (HSDB, 2000; Budavari, 1996)
d) 17 mg/kg (ITI, 1995)
e) 14 mg/kg
f) 13.3 mg/kg

4) LD50- (SKIN)RAT:

a) 17 mg/kg (ITI, 1995)
b) 140 mg/kg (Clayton & Clayton, 1994)

5) LD50- (SUBCUTANEOUS)RAT:

a) 8500 mcg/kg

Pharmacology Toxicology

Toxicologic Mechanism

A)

Physicochemical

Physical Characteristics

A)

B)

Molecular Weight

A)

Other

A)

1) 3 ppm (4 mg/m(3) for 15M) (Snyder et al, 1990)

Animal Toxicology

References

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ACETONE CYANOHYDRIN

Classification | Detailed evidence-based information

Therapeutic Toxic Class

Specific Substances

Available Forms Sources

Life Support

Clinical Effects

Laboratory Monitoring

Treatment Overview

Range Of Toxicity

Summary Of Exposure

Heent

Cardiovascular

Respiratory

Neurologic

Gastrointestinal

Hepatic

Genitourinary

Acid-Base

Hematologic

Dermatologic

Reproductive

Carcinogenicity

Genotoxicity

Monitoring Parameters Levels

Radiographic Studies

Methods

Life Support

Patient Disposition

Monitoring

Oral Exposure

Inhalation Exposure

Eye Exposure

Dermal Exposure

Enhanced Elimination

Case Reports

Summary

Minimum Lethal Exposure

Maximum Tolerated Exposure

Workplace Standards

Toxicity Information

Toxicologic Mechanism

Physical Characteristics

Molecular Weight

Other

General Bibliography