Diana María González.María Angélica Palencia.

Andrea Jimena Santamaría.

May 2010 XI Semester

METHANOL AND CYANIDE

INTOXICATION

THIS WEEK !!!!!!Half of the suicidal deaths

are younger than 30!!!!!

The majority of suicides are MEN

Beteween 20 and 24 years. Many had drug problems or

ALCOHOL DEPENDENCEPOISONING 465 CASES

http://www.eltiempo.com/archivo/documento/MAM-3951687

Articles

I. General AspectsII. EpidemiologyIII. Materials and MethodsIV. PhysiopathologyV. ResultsVI. DiscussionVII.ConclusionsVIII. Questions

Table of Contents

• Intoxication : the state of being affected by one or more psychoactive drugs. It can also refer to the effects caused by the ingestion of poison or by the overconsumption of normally harmless substances.

General Aspects

• Methanol: A colorless, toxic, flammable liquid, used as an antifreeze, a general solvent, a fuel, and a denaturant for ethyl alcohol. Also called carbinol, methyl alcohol, wood alcohol, wood spirits.

General Aspects

• Cyanide: Any of various salts or esters of hydrogen cyanide containing a CN group, especially the extremely poisonous compounds potassium cyanide and sodium cyanide.

General Aspects

METHANOL INTOXICATION CYANIDE INTOXICATIONWorld-wide problem, and in some regions it is connected with high morbidity and mortality.

The major routes are:• Inhalation• Topical exposure• Oral

Methanol is found commonly in:• Antifreeze• Perfumes• Solvents• Commercial formaldehyde• Ilegal alcohol

Deaths due to cyanide poisoning are relatively rare.

•Smoke inhalation.•Industry, particularly in the metal trades, mining, electroplating, jewelry manufacturing, and x-ray film recovery, fumigation .

• Used as suicidal agents, particularly among healthcare and laboratory workers.

•Potentially terrorist attack.

Epidemiology

Materials and Methods

17 methanol poisoning cases.

The brains of 17 cases after being fixed for 2 weeks in 10% formalin.

The samples were embedded in paraffin and then were stained with hematoxylin.

All samples are sent to the toxicology section of the Council of Forensic Medicine to determine drugs and ethanol/methanol.

Ante-mortem samples.

Postmortem specimens

Sample preparation for neuropathology

Sample preparation for analysis of methanol levels

Chemicals and reagents

Instrumentation and chromatographic conditions

Data processing

Validation of the analytical method

Determination of cyanide was performed by a spectrophotometric method after microdiffusion.

5 cases report: cases 1 through 4 were analyzed in Bon and case 5 was analyzed in Duesseldorf.

PHYSIOPATHOLOGY

Physiopatology MethanolEarly stage poisoning

Formaldehyde

Formate ACIDOSIS

OCULAR TOXICITY

GENERAL TOXICITY

ACIDOSIS

Late stage poisoning

Inhibition of the mitochondrial respiration

Methanol

Increased formate toxicityCirculatory Failure

Circulatory Failure

CIRCULUS HIPOXICUS

TISSUE HYPOXIA

CYANIDE (HCN)LUNGS

GASTROINTESTINAL TRACTSKIN

INACTIVATION OF CYTOCHROME OXIDASE

INHIBITS CELLULAR RESPIRATION

NauseaVomitingAcidosisConvulsionDEATH

Physiopatology Cyanide

RESULTS

CASE AGE CLINICAL Treatment

1 39 Deep ComaBrain death diagnosis

EthanolFolic Acid

BicarbonateHemodialysis

2 34 Deep Coma

EthanolFolic Acid

BicarbonateHemodialysis

3 44 Death None

Metanol Intoxication

Macroscopic changes

Brain Stem

Cerebel-lum

heart-blood

Femoral vein

blood

Urine Vitreous humor

Liquor Lung Bile Kidney Liver Gastric contens

Synovial fluid

Case 1 738 1828 5 5 25 8 0 0 12 0 0 95 0

100

300

500

700

900

1100

1300

1500

1700

1900

Case 1

Met

hano

l con

cent

rati

ons

Mg/

L or

g/K

g

Metanol concentrations

Brain Stem

Cerebellum

heartblood

Femoral vein blood

Urine

Vitreous humor

Liquor

Lung

Bile

Kidney

Liver

Gastric contens

Synovial fluid

Case 2

1008

0254

228

247

201

351

249

256

230

238

248

268

100

300

500

Case 2

Met

hano

l con

cent

ratio

ns M

g/L o

r g/K

g

Metanol Intoxication

Brain Stem

Cerebellum

heartblood

Femoral vein blood

Urine

Vitreous humor

Liquor

Lung

Bile

Kidney

Liver

Gastric contens

Synovial fluid

Case 3

2213

1811

2130

2074

2488

2122

2289

02180

01808

2200

0

250

750

1250

Case 3

Met

hano

l con

cent

ratio

ns M

g/L o

r g/K

g

Metanol concentrations

Cyanide Intoxication: Case 1

AGE External Examination Internal Examination Toxicology38 year old

•Livor mortis of inconspicuous coloration

•Petechiae and purpura

•Intense congestion of the face

•Fatty liver

• Visceral congestion

•Stomach: Viscuous brown fluid

•Cyanide:Blood: 80,9 Mg/LGastric: 1,26 g/LLung: 46,3Brain: 4,8 mg/Kg

AGE External Examination

Internal Examination

Toxicology

71 years old

• Both corpses revealed no major

injury• Livor mortis of purple coloration

• Non performed Cyanide:•Blood: 6,1 Mg/L• and: 8,6 Mg/Ml

Cyanide Intoxication: Cases 2 & 3

AGE External Examination

Internal Examination

Toxicology

70 year old

• Coloration of livor mortis

•Severe atherosclerosis with fibrofatty plaques and 2 surgical aortocoronary bypass vessels

Cyanide:•Blood: 42,5 Mg/L

Cyanide Intoxication: Case 4

Cyanide Intoxication: Case 5

AGE External Examination

Internal Examination

Toxicology

29 year old

• Coloration of livor mortis

• Atherosclerosis with fibroftty plaques and 2

surgical aortocoronary bypass vessels

Cyanide:Blood: 42,5 Mg/Land: 8,6 Mg/Ml

Macroscopic changes

Macroscopic changes

DISCUSSION

Cyanide salts are generally colorless solid or colorless gas at room temperature.

The ability to smell cyanide is a genetically determined trait absent in 50%.

Each pack of cigarettes releases 250 to 10,000g of cyanide

Faint, bitter almond odor. May be released by pyrolysis.

Discussion

Cyanide Intoxication

CLINICAL PRESENTATIONS TOXICOLOGICFINDINGS

Symptoms in seconds of inhalation and within minutes after the ingestion.

Lightheadedness, giddiness, tachypnea, nausea, vomiting, suffocation, confusion, restlessness, anxiety, slow heart rate.

Hypoventilation, apnea and myocardial depression.

<0.2 mg/L do not cause symptoms.

Smokers may reach 0.4 mg/L without symptoms.

0.5 and 1.0 mg/L: conscious, flushed, and tachycardic.

Stupor and agitation can appear with peak blood levels between 1.0 and 2.5 mg/L.

Discussion

INDICATIVE CIRCUMSTANCES OF CYANIDE POISONING PATHOLOGIC FINDINGS

Acrylate or nitric manufacturers andusersBlacksmithsOyeingElectroplatingMetal heat treatment processesMineral refiningPaper manufacturesPest controlPhotographyPlastic manufacturesPrintingTanning

Nonspecific

The bright pink or lilac coloration is difficult or impossible to detect

• Hemorrhagic appearance ofthe gastric mucosa.

• Vacuolation of the basal mucosal cells, desquamation of surface epithelial cells, inflammatory infiltration of the submucosa.

Discussion

Discussion

METHANOL

Nausea, vomiting, abdominal pain, visual disturbances, and mental status changes after a 12 to 24 hours latent period.

Severe intoxication: delirium, convulsions, coma, cardiopulmonary failure, and death.In our cases, death occurred from the unwitting ingestion of methanol. Eight cases /visual disorder.In acute methanol intoxication the brain is swollen and congested and there may be petecchial hemorrhages. (putaminal hemorrhage)

• Petecchial hemorrhages in the occipital, temporal and parietal cortex, and basal ganglia.

• Hemorrhagic necrosis: thalamus, putamen, and globus pallidus in 5 cases, and at cerebral cortex in 3 cases.

• While 3 of the cases with cerebral edema were accompanied by herniation of the brain, 2 cases had pons hemorrhages.

• Two of the cases with hemorrhagic necrosis around basal ganglia ventricular compression .

• Survival times from few hours to 10 days.

Discussion

DISCUSSION

Concentration of methanol in postmortem specimens

1. Hemodialysis can effectively reduce toxic blood methanol concentrations.

2. Determination of blood levels does not reliably reflect brain methanol concentrations.

3. If a patient presents in a coma, the narcotic properties of methanol should be kept in mind before starting brain death diagnosis

4. if fatal methanol intoxication is suspected, brain methanol analysis should be performed after autopsy, and blood analysis to avoid that cases with longer survival times escape detection.

Conclussions

5. Sporadic or epidemic accidental use of methyl alcohol, is one of the major forensic problems.

6. Cases susceptible to methyl alcohol poisoning, many topographic sampling should be carried out primarily at the cerebral cortex and from various parts of the brain, and the same should be analyzed by an experienced neuropathologist.

Conclussions

• Diagnosis of cyanide intoxication cannot reliably be established at autopsy recognize or may even be completely missing.

• considerable caution should be exercised in an attempt to smell cyanide, because this procedure is associated with the risk of inhaling cyanide fumes.

Conclussion

Congratulations new interns, this was our final magazine club!!! THX Dr. Hernandez!!!