Potential therapies for sodium azide intoxication; a case report and review of the literature

Abstract

Intoxications with sodium azide are rare and in almost all cases lethal in doses above 700 mg or 10mg/kg. We report a case of a patient who ingested 2 grams of sodium azide as a suicide attempt. Sodium azide irreversible blocks cytochrome C oxidase by inhibiting oxidative phosphorylation leading to cell death. There is currently no antidote available. Our patient was treated with a range of therapies, on site, in the emergency department and in the intensive care unit, such as sodium thiosulphate, methylene blue, intralipid, extensive gastric lavage, whole bowel irrigation combined with pro-kinetics, hydroxocobalamin and exchange transfusion. During the clinical course the patient developed cardiac failure, for which veno-arterial ECMO and an intra-aortic balloon pump was placed. However, cardiac function did not recover, leading to discontinuation of treatment after 7 days. As literature on sodium azide intoxication is scarce, we conducted a review to present potential treatment options.

Internet-Purchased Sodium Azide Used in a Fatal Suicide Attempt: A Case Report and Review of the Literature

“…However, to date, no cases have been reported in which methylene blue has been successfully used as an antidote. Other case reports described a variety of therapeutic supportive care interventions, including sodium thiosulfate, intralipid, gastric lavage with activated charcoal, hydroxocobalamin, dopamine, dobutamine, methylprednisolone, calcium gluconate, insulin/glucose, sodium bicarbonate, and adrenaline [ 4 , 14 , 23 , 24 ]. Despite extensive and aggressive supportive care measures such as exchange transfusion or dialysis, in addition to the above-described therapeutic strategies, all of these individuals had to be resuscitated, and all were unsuccessful [ 4 , 14 , 23 , 24 ].…”

“…Other case reports described a variety of therapeutic supportive care interventions, including sodium thiosulfate, intralipid, gastric lavage with activated charcoal, hydroxocobalamin, dopamine, dobutamine, methylprednisolone, calcium gluconate, insulin/glucose, sodium bicarbonate, and adrenaline [ 4 , 14 , 23 , 24 ]. Despite extensive and aggressive supportive care measures such as exchange transfusion or dialysis, in addition to the above-described therapeutic strategies, all of these individuals had to be resuscitated, and all were unsuccessful [ 4 , 14 , 23 , 24 ]. However, it is suggested that there might be a window of opportunity for the use of exchange transfusions or dialysis if applied before systemic effects [ 4 ] and in patients with no severe hemodynamic symptoms [ 14 ].…”

“…Despite extensive and aggressive supportive care measures such as exchange transfusion or dialysis, in addition to the above-described therapeutic strategies, all of these individuals had to be resuscitated, and all were unsuccessful [ 4 , 14 , 23 , 24 ]. However, it is suggested that there might be a window of opportunity for the use of exchange transfusions or dialysis if applied before systemic effects [ 4 ] and in patients with no severe hemodynamic symptoms [ 14 ]. Due to the rapid onset of symptoms after a (high) dose of sodium azide, this treatment window may be limited.…”

“…Lower doses may result in nausea, vomiting, hypotension, tachycardia, and headaches, whereas higher doses can lead to prolonged hypotension, dysrhythmias, acidosis, seizures, and eventually death [13]. Lethal doses are reported to be above 700 mg or 10 mg/kg [14,15], while toxic doses are reported to be between 20 and 180 mg [15]. The average time between ingestion and death is 4.5 h [1].…”

A case report of sodium azide-induced myopericarditis

“…Sodium azide ingestions are rare with a recent review identifying 156 cases of both accidental and intentional exposures between 2000 and 2020. 1 , 2 The substance is mostly used as a propellant in vehicular airbags but has also been used in laboratory, pharmacy, or industrial settings as a reagent probe, biocide, and chemical preservative. 1 The substance’s widespread availability (even through online retailers) and its prior use in terrorist attacks render this an important toxin for clinicians to be aware of.…”