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ADVERTISEMENT CONSIDER ANOTHER SIDE OF While carbon monoxide (CO) is a well-known danger in fire smoke, cyanide (CN) is another side of smoke that deserves considerable attention. Yet there is a lack of awareness about CN poisoning that may hamper effective prehospital treatment.1,2 CN can be released by virtually any material containing carbon and nitrogen when burned under certain circumstances.3,4 It is frequently found in the smoke of closed-space fires where the potential for CN toxicity is augmented due to both the increased use of CN-containing synthetic materials and decreased ventilation in many buildings.1,3 Given the prevalence of CN in fire smoke, the risk of CN poisoning should be considered for smoke-inhalation victims. Moderate to high concentrations of CN can cause severe injury and death within minutes.1,5 nervous system dysfunction (eg, intellectual impairment, Parkinsonism, and personality changes).6 One of the key challenges in treating CN poisoning is that the symptoms can be difficult to differentiate from those of CO poisoning. CO poisoning can readily be assessed using a transcutaneous CO-oximeter. Currently, there is no diagnostic test to confirm CN poisoning within the limited window for initiating potentially lifesaving treatment.7,8 measurement of CN is not available.8 Even at most hospitals, rapid Because there is no rapid test to confirm CN poisoning and it can quickly become fatal, the decision to treat empirically could save lives.1,8 manifestations are present1 CN poisoning should be suspected if the following : • Exposure to fire or smoke in an enclosed area • Soot around mouth, nose, or back of mouth • Altered mental status CN has a devastating impact on smoke-inhalation victims, but with early recognition and prompt response, there is the potential to save lives.9 References: 1. Eckstein M, Maniscalco PM. Focus on smoke inhalation—the most common cause of acute cyanide poisoning. Prehosp Disaster Med. 2006;21(2):S49-S55. 2. Alcorta R. Smoke inhalation & acute cyanide poisoning. In: Losavio K, ed. Smoke Inhalation & Hydrogen Cyanide Poisoning. San Diego, CA: JEMS Communications; 2004:1-31. 3.Walsh DW, Eckstein M. Hydrogen cyanide in fire smoke: an underappreciated threat. Emerg Med Serv. 2004;33(10):160-163. 4. Agency for Toxic Substances and Disease Registry. Cyanide toxicity. Am Fam Physician.1993;48(1):107-114. 5. Holstege CP, Isom GE, Kirk MA. Cyanide and hydrogen sulfide. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrank's Toxicologic Emergencies. 8th ed. New York, NY: McGraw-Hill; 2006:1712-1757. 6. Lee-Chiong TL Jr. Smoke inhalation injury: when to suspect and how to treat. Postgrad Med. 1999;105(2):55-62. 7. Baud FJ. Cyanide: critical issues in diagnosis and treatment. Hum Exp Toxicol. 2007;26(3):191-201. 8. O'Brien DJ, Augustine J, Walsh DW. Cyanide exposure, smoke inhalation, and pre-hospital treatment: recognizing the signs and symptoms and available treatment options. In: Smoke: Cyanide and Carbon Monoxide: The Toxic Twins of Smoke Inhalation. Indianapolis, IN: Cyanide Poisoning Treatment Coalition; 2009:1-28. 9. Maniscalco PM. From smoke inhalation to chemical attacks: acute cyanide poisoning in the prehospital setting. Prehosp Disaster Med. 2006;21(2):S38-S39. Copyright © 2010 Meridian Medical Technologies™, Inc., a wholly owned subsidiary of King Pharmaceuticals® All rights reserved. MMT7259 07/2010 For More Information Circle 13 on Reader Service Card , Inc. In addition, individuals who survive are at risk for central