Sodium azide poisoning: a narrative review

Figures & data

Figure 1. Peer-reviewed articles concerning human cases of NaN₃ or HN₃ exposure.

Figure 2. News articles concerning human cases of NaN₃ or HN₃ exposure.

Table 1. Review of 37 peer-reviewed papers yielded 106 cases.

1A-1. Accidental exposure due to airbag deployment
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Corazza et al. [24]	VII	1	Male	35	Dermal contact	First-degree burns Irritant contact dermatitis	Yes	Topical steroids	Yes
Foley and Helm [25]	VII	1	Female	32	Dermal contact	First-degree burns	Yes	Topical antibiotics	Yes
Corazza et al. [33]	VII	1	Male	36	Dermal contact	First and second-degree burns	Yes	Topical antibiotics	Yes
Wu et al. [26]	VII	1	Female	29	Dermal contact	Irritant contact dermatitis	Yes	Topical and oral steroids	Yes
Suhr and Kreusch [27]	VII	1	Female	73	Dermal contact	Second-degree burns	Yes	Topical antibiotics	Yes
Hambrook and Fink [28]	VII	1	Male	47	Inhalation	Asthma Chest tightness Cough	Yes	β-agonists Inhaled steroids	Yes
Caudle et al. [29]	VII	1	Male	18	Inhalation	Chemical pneumonitis Dyspnea Hemoptysis	Yes	Oral steroids Oxygen	Yes
Belhadj-Tahar et al. [32]	VII	1	Male	37	Inhalation and dermal contact	Burning eyes Dyspnea	Yes	Ocular irrigation Supplemental oxygen	Yes
Francis et al. [9]	VII	1	Male	22	Inhalation and dermal contact	Alkaline ocular injury Erythematous supraglottis Stridor Tachypnea	Yes	Mechanical ventilation Ocular irrigation Steroids	Yes
Govindarajan et al. [30]	VII	1	Male	56	Inhalation	Chemical pneumonitis	Yes	N/A	Yes
Sever et al. [31]	VII	3	Female	21	Dermal contact	All three had second- degree burns One patient had alkaline ocular injury	Yes	Standard burn care Victim with ocular burn received additional ophthalmic care	Yes
			Male	39 33
1A-2. Accidental exposure due to industrial work
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Pham et al. [36]	VII	1	Male	29	Inhalation and dermal contact	Bradycardia Hypotension Metabolic acidosis Third-degree burns	Yes	Intravenous fluids Mechanical ventilation Sodium bicarbonate Vasopressors	No
Miljours and Braun [34]	IV	41	Unknown	Median age not available	Inhalation	Burning eyes Dizziness Headache Palpitations	No	Unknown	Yes
Fang et al. [35]	VII	1	Male	32	Inhalation and dermal contact	Diplopia Dizziness Paresthesias Reduced muscle strength	Yes	Hyperbaric oxygen Steroids Traditional Chinese medicines Vitamins B1, B12, and C	Yes
1A-3. Accidental exposure in a laboratory
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Angelotti et al. [39]	VII	1	Male	33	Dermal contact (13 g)	Burns Hypotension Lacerations	Yes	Amputation Mechanical ventilation Vasopressors Wound care	Yes
1A-4. Accidental exposure in a medical facility
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Watanabe et al. [47]	VII	1	Female	53	Ingestion (1 g)	Generalized seizures Hypotension Metabolic acidosis	Yes	Hemodialysis Gastric lavage with activated charcoal Intra-aortic balloon pump Intravenous steroids Mechanical ventilation Vasopressors	Yes
Dermican et al. [46]	VII	1	Female	25	Ingestion (0.1 g)	Generalized seizures Headache Vomiting	Yes	Gastric lavage	Yes
1B-1. Suicide in a laboratory setting
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Spadafora et al. [40]	VII	1	Female	Unknown	Ingestion (>10 g)	Bradycardia Coma Hypoxia Metabolic acidosis	Yes	Unknown	No
Senda et al. [50]	VII	1	Female	25	Ingestion	Acute respiratory distress syndrome Arrythmia Cardiac arrest Coma Metabolic acidosis	Yes	Gastric lavage Intravenous steroids Mechanical ventilation Sodium bicarbonate	No
Fuyuno and Cyranoski [51]	VII	1	Male	42	Ingestion	N/A	No (found dead)	N/A	No
Łopaciński et al. [52]	VII	2	Male	30	Ingestion (>0.18 g)	Dizziness Metabolic acidosis Tachycardia	Yes	Inhaled amyl nitrite Intravenous sodium nitrite Intravenous sodium thiosulfate	Yes
				23	Ingestion (10 g)	Arrythmia Cardiac arrest Coma Metabolic acidosis	Yes		No
Meatherall and Palatnick [53]	VII	1	Male	59	Ingestion	Arrythmia Cardiogenic shock Coma Hypotension Metabolic acidosis	Yes	Exchange transfusion Inhaled amyl nitrite Intravenous sodium nitrite Intravenous sodium thiosulfate Mechanical ventilation Sodium bicarbonate Vasopressors	No
French et al. [54]	VII	1	Male	28	Ingestion (0.1 g)	Bradycardia Hypotension Metabolic acidosis	Yes	Intravenous fluids Gastric lavage Sodium bicarbonate	Yes
Kostek et al. [55]	VII	1	Female	55	Ingestion (0.6 g)	Metabolic acidosis	Yes	Gastric lavage	Yes
Le Blanc-Louvry et al. [56]	VII	1	Male	35	Ingestion (6 g)	N/A	No (found dead)	N/A	No
Bartecka-Mino et al. [57]	VII	1	Female	25	Ingestion	Coma Hypotension Metabolic acidosis	Yes	Hydroxocobalamin Vasopressors	Yes
Downes et al. [58]^a	VII	1	Male	32	Ingestion	Hypotension Metabolic acidosis	Yes	Intravenous fluids Vasopressors	No
Gao et al. [60]^b	VII	1	Male	23	Ingestion (1.38 g)	Chest pain Hypotension Metabolic acidosis Nausea and vomiting	Yes	Hemodialysis Intravenous crystalloid Norepinephrine	Yes
Muvalia et al. [59]	VII	1	Female	19	Ingestion (50 g)	Coma Hypotension Metabolic acidosis Nausea and vomiting	Yes	Mechanical ventilation Vasopressors	No
1B-2. Suicide in a non-laboratory setting
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Wiergowski et al. [61]	VII	1	Male	19	Ingestion (∼20 g)	N/A	No (found dead)	N/A	No
Meatherall and Oleschuk [53]	VII	1	Male	35	Ingestion	N/A	No (found dead)	N/A	No
Overtchouk et al. [63]	VII	1	Female	69	Ingestion (15 g)	Myocardial dysfunction Metabolic acidosis	Yes	Gastric lavage Intravenous fluids	Yes
Rojek et al. [64]	VII	1	Female	50	Ingestion	Bradycardia Coma Hypotension	Yes	Mechanical ventilation Vasopressors	No
Ciesla et al. [65]	VII	1	Male	24	Ingestion	Coma	Yes	Unknown	No
Leonard et al. [2]	VII	1	Male	22	Ingestion (40 g)	Arrhythmia Cardiac arrest Hypotension Metabolic acidosis	Yes	Mechanical ventilation	No
1C. Secondary exposure of emergency medical personnel
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Hirose et al. [73]^c	VII	6	Unknown	Unknown	Inhalation	Burning eyes Dizziness Dyspnea Headache	No	Unknown	Yes
Downes et al. [58]^a	VII	10	5 Males	39 (median)	Inhalation and dermal contact	1 case reported fatigue 1 case reported stress	No	Time off from work for the two cases	Yes
			5 Females
1D. Unknown exposure
Publication	Level of evidence	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Treatment	Survival
Hirose et al. [73]^c	VII	7	1 Female	22	Ingestion	Dizziness Hypotension Palpitations Paresthesias Syncope	Yes	Gastric lavage Inhaled amyl nitrite Intravenous sodium nitrite Intravenous sodium thiosulfate Vasopressors	Yes
			6 Males	20 24 24 25 43 55
Schwarz et al. [74]	VII	5	3 Females	Median age not available	Ingestion	Arrhythmia Headache Hypotension	Yes	Intravenous fluids Oral antiemetics	Yes
			2 Males

They are grouped based on mode of azide exposure (i.e., accidental, suicidal, secondary, and unknown, letters A through D, respectively) and sub-grouped based on exposure setting (numbers 1 through 4). Unless indicated, an entry is a primary patient.

^aDownes et al. [58] reported a total of 11 patients. The primary victim committed suicide by azide ingestion and is described in Table 1(B-1). Ten medical personnel who treated the patient are described in Table 1(C).

^bAlthough not in the abstract, we contacted the corresponding author who confirmed the patient ingested azide to commit suicide.

^cTen patients were exposed to azide and hospitalized. Hirose worked at the hospital where seven of the patients were treated. Hence, the paper provided data on only those seven victims; they are summarized in Table 1(D) (information was not provided on whether poisoning was intentional or accidental). Six medical personnel who treated the seven azide-poisoned patients presented symptoms consistent with low-dose azide exposure, likely via inhaling HN₃ gas released when performing gastric lavage on the patients. They are described in Table 1(C).

Table 2. Review of 17 news articles yielded 50 cases.

2A-1. Accidental exposure due to industrial work
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
Perkins [37]	1	Male	45	Dermal contact	Burned >15% of body	Yes	No
2A-2. Accidental exposure in a laboratory
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
Green [41]	1	Male	Unknown	Dermal Contact (65 g)	Burns	Yes	Yes
Author unknown [44]	1	Male	Unknown	Ingestion	Unknown	Yes	Yes
Lillington [40]	11	Unknown	Unknown	Inhalation	Unknown	Yes	Yes
Crabbe [42]^a	1	Male	27	Dermal contact	Facial burns Glass embedded in chest and abdomen Minor lacerations	Yes	Yes
Kemsley [43]	1	Male	Unknown	Dermal contact (200 g)	Second-degree burns Minor lacerations	Yes	Yes
Author unknown [45]	1	Male	Unknown	Dermal contact	Minor lacerations	Yes	Yes
2A-3. Accidental exposure in a medical facility
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
Author unknown [48]	1	Male	66	Ingestion (1.5 g)	Rapid deterioration Vomiting	Yes	No
2B. Suicide in a non-laboratory setting
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
DeMare [67]^b	1	Female	32	Ingestion	Unknown	No (found dead)	No
Stout [68]^c	1	Female	25	Ingestion	Unknown	Yes	No
Bender [66]	1	Female	71	Ingestion	N/A	No (found dead)	No
Singh [69]	1	Male	21	Ingestion	Unknown	Yes	No
Hicks [70]^d	1	Male	27	Unknown	N/A	No (found dead)	No
2C. Homicide
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
Author unknown [48]	3	Unknown	Unknown	Ingestion (20 g)	Unknown	1 Yes	Yes
						2 No
State of Arizona, Appellee, v. Wendi Elizabeth Adriano, Appellant [72]	1	Male	33	Ingestion (possibly 21 g)	N/A	No (found dead)	No
2D. Secondary occupational exposure of medical personnel
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
DeMare [67]^b	5	Unknown	Unknown	Unknown	Minor respiratory symptoms	Yes	Yes
Crabbe [42]^a	1	Male	25	Dermal contact	Facial and corneal burns	Yes	Yes
Stout [68]^c	6	Unknown	Unknown	Unknown	Unknown	Yes	Yes
Hicks [70]^d	1	Unknown	Unknown	Unknown	Unknown	Yes	Yes
2E. Unknown exposure
Publication	Number of cases	Gender	Age	Exposure route	Clinical features	Hospitalization	Survival
Author unknown [75]	6	1 Male	Unknown	Ingestion	Dizziness Syncope Tinnitus	Yes	Yes
		1 Female
		4 unknown
Author unknown [76]	4	Unknown	Unknown	Ingestion	Dizziness Lightheadedness	Yes	Yes

They are grouped based on mode of azide exposure (i.e., accidental, suicidal, homicidal, secondary, and unknown, letters A through E, respectively) and sub-grouped based on exposure setting (numbers 1 through 3). Unless indicated, an entry is a primary patient.

^aCrabbe [42] reported two patients. The primary victim was exposed to azide in a laboratory explosion and is described Table 2(A-2). A firefighter was exposed to azide while responding to the primary victim and is described in Table 2(D).

^bDeMare [67] reported six patients. The primary victim committed suicide by ingesting azide and is described Table 2(B). Five emergency response personnel who came into contact with the primary victim are described in Table 2(D).

^cStout [68] reported seven patients. The primary victim committed suicide by ingesting azide and is described Table 2(B). Six emergency response personnel who came into contact with the primary victim are described in Table 2(D).

^dHicks [70] reported two patients. The primary victim committed suicide with azide via an unknown route and is described Table 2(B). Among personnel who responded to the victim, one officer was hospitalized for observation and is described in Table 2(D).

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