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Cyanide: An Old Enemy With Heightened Risks
CYANIDE SUPPLEMENT
Cyanide: An Old Enemy With Heightened Risks
Author: Mary Jo Koschel, MSN, NR-EMT-P, Fort Collins, Colo
Mary Jo Koschel, Poudre Valley Hospital Trauma Services, Fort Collins, Colo. For correspondence, write: Mary Jo Koschel, MSN, NR-EMT-P, Poudre Valley Hospital Trauma Services, 1024 S Lemay Ave, Fort Collins, CO; E-mail: [email protected]. J Emerg Nurs 2006;32:S1-2. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.05.009
August 2006
32:4S
C
yanide is an old enemy of human health. One of the most notorious of poisons, cyanide has caused both accidental and purposeful human fatality since antiquity.1 In Rome during the first century, long before cyanide was identified or named, the Emperor Nero allegedly used the cyanogenic plant cherry laurel to kill enemies. Cyanide continued to be used through the centuries as an agent of suicide and genocide and a weapon of war.2 Histories of 20th century warfare are peppered with references to cyanide, purportedly used by France in World War I, Japan in World War II, the Nazis in World War II, and Iraq in the 1980s. Cyanide remains a viable weapon in the 21st century as exemplified by its planned or actual use in terrorism including the 1993 World Trade Center bombing, the 1995 Tokyo subway attack, the 2002 plot to poison the water supply to the American Embassy in Rome, and the alleged amassment by ‘‘Dr. Chaos’’ of more than 1 pound of cyanide in the Chicago subway system in 2002.1Q3 The latter examples show that, its status as an old enemy notwithstanding, cyanide is a current threat to human health. Today, cyanide is associated with heightened risks. Always a relatively accessible poison, cyanide might be more readily available today than ever before with the advent of widespread use of the Internet. In the study ‘‘Look What I Found! Poison Hunting on eBay,’’ cyanide was among the poisons advertised as available for sale in searches of the online auction web site over the 10-month period from May 2003 to February 2004.4 The perpetrator in the 2003 cyanide murder of a Baltimore teenager obtained cyanide over the Internet from a chemical and laboratory-supply company.5,6 The potential availability of
JOURNAL OF EMERGENCY NURSING
S1
CYANIDE SUPPLEMENT/Koschel
cyanide to anyone who can access the Internet gives unprecedented ease of access to the poison. Another heightened risk of cyanide is associated with inadvertent exposure to it as a combustion product in fire smoke. Today in the United States, smoke inhalation, rather than purposeful use of cyanide to inf lict harm, is the most common cause of acute cyanide poisoning.7,8 Cyanide is generated by the burning of carbon- and nitrogencontaining substances. Although cyanide substrates have always been common in occupied structures, they are becoming more plentiful with people’s increasing reliance on synthetics, which are particularly rich cyanide substrates. Substances such as plastic, polyurethane, and nylon can produce large quantities of cyanide when burned. Partly because of people’s increasing reliance on the nitrogen- and carbon-containing products of the polymer industry, the risk of human exposure to cyanide in the structural fire is arguably greater than ever before. This risk is illustrated by a press report of 5 firefighters who tested positive for cyanide poisoning after fighting a fire at a Providence, Rhode Island, restaurant in March, 2006.9 A very large amount of insulation made of Styrofoam, a cyanide substrate, burned during the fire. Cyanide, this old enemy with heightened risks, should be a topic of importance to emergency nurses. Among the first health care professionals to administer care to victims of poisoning, emergency nurses can play a pivotal role in the recognition and treatment of acute cyanide poisoning. This supplement discusses current understanding of the causes and consequences of acute cyanide poisoning and its recognition and clinical management. Sources of human exposure to cyanide are numerous. In his article, ‘‘Cyanide: Sources, Perceptions, and Risks,’’ Captain Rob Schnepp, Hazardous Materials Specialist with the Alameda County Fire Department, discusses both wellrecognized and lesser-known sources of acute exposure to cyanide. He describes recent data suggesting that cyanide is often as important as carbon monoxide as a toxicant in fire smoke. He also considers current concern about the threat of cyanide exposure in a terrorist attack. Cyanide is among the most rapidly acting and lethal of poisons—factors that make its recognition and management particularly challenging. Dr. Lewis Nelson of the New York City Poison Control Center summarizes the
S2
mechanisms of cyanide toxicity in his article, ‘‘Acute Cyanide Toxicity: Mechanisms and Manifestations.’’ Nelson relates the cellular and tissue effects of cyanide to the clinical manifestations of acute cyanide poisoning. Understanding how cyanide’s physiologic effects bring about specific clinical manifestations is helpful in the recognition of acute cyanide poisoning. The articles ‘‘Recognition and Treatment of Acute Cyanide Poisoning’’ by Dr. Stephen W. Borron of the University of Texas Health Science Center and ‘‘Management of the Cyanide-Poisoned Patient’’ by this author discuss the recognition and treatment of acute cyanide poisoning from a practical perspective. These articles cover all phases of care including prehospital, emergency department, and continuing care. Emergency nurses regardless of specialty—whether prehospital, f light, pediatric, trauma, triage, or advanced practice—may face the clinical challenge of treating the patient poisoned with cyanide. Effective care of the cyanidepoisoned patient by emergency nurses can save lives. The information in this supplement provides the emergency nurse with an increased awareness and knowledge base to reduce death and injury from cyanide poisoning. REFERENCES 1. Gracia R. Cyanide. In: Keyes DC, editor. Medical response to terrorism: preparedness and clinical practice. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 26-37. 2. Eckstein M. Cyanide as a chemical terrorism weapon. JEMS 2004; 29(suppl):22-31. 3. Sauer SW, Keim ME. Hydroxocobalamin: improved public health readiness for cyanide disasters. Ann Emerg Med 2001;37: 635-41. 4. Cantrell FL. Look what I found! Poison hunting on eBay. Clin Toxicol 2005;43:375-9. 5. Stewart K. Chemical company investigated. Louisville CourierJournal, March 26, 2006. 6. Peddy SB, Rigby MR, Shaffner DH. Acute cyanide poisoning. Pediatr Crit Care Med 2006;7:79-82. 7. Walsh DW, O’Brien DJ, Arnold JL. Cyanide poisoning: not just a HAZMAT issue. fireEMS, September 2004. Available from URL: fe.pennnet.com/Articles/Article_Display.cfm?Section= Articles&ARTICLE_ID=212520&VERSION_NUM=1&p=71. Accessed December 5, 2005. 8. Walsh DW, Eckstein M. Hydrogen cyanide in fire smoke: an under appreciated threat. Emerg Med Serv 2004;33:160-63. 9. Anonymous. Providence firefighters treated for exposure to cyanide. Available from URL: www.boston.com/news/local/rhode_ island/articles/2006/03/24/providence_firefighters_treated_for_ exposure_to_cyanide/. Accessed March 28, 2006.
JOURNAL OF EMERGENCY NURSING
32:4S
August 2006
Cyanide: An Old Enemy With Heightened Risks
Author: Mary Jo Koschel, MSN, NR-EMT-P, Fort Collins, Colo
Mary Jo Koschel, Poudre Valley Hospital Trauma Services, Fort Collins, Colo. For correspondence, write: Mary Jo Koschel, MSN, NR-EMT-P, Poudre Valley Hospital Trauma Services, 1024 S Lemay Ave, Fort Collins, CO; E-mail: [email protected]. J Emerg Nurs 2006;32:S1-2. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.05.009
August 2006
32:4S
C
yanide is an old enemy of human health. One of the most notorious of poisons, cyanide has caused both accidental and purposeful human fatality since antiquity.1 In Rome during the first century, long before cyanide was identified or named, the Emperor Nero allegedly used the cyanogenic plant cherry laurel to kill enemies. Cyanide continued to be used through the centuries as an agent of suicide and genocide and a weapon of war.2 Histories of 20th century warfare are peppered with references to cyanide, purportedly used by France in World War I, Japan in World War II, the Nazis in World War II, and Iraq in the 1980s. Cyanide remains a viable weapon in the 21st century as exemplified by its planned or actual use in terrorism including the 1993 World Trade Center bombing, the 1995 Tokyo subway attack, the 2002 plot to poison the water supply to the American Embassy in Rome, and the alleged amassment by ‘‘Dr. Chaos’’ of more than 1 pound of cyanide in the Chicago subway system in 2002.1Q3 The latter examples show that, its status as an old enemy notwithstanding, cyanide is a current threat to human health. Today, cyanide is associated with heightened risks. Always a relatively accessible poison, cyanide might be more readily available today than ever before with the advent of widespread use of the Internet. In the study ‘‘Look What I Found! Poison Hunting on eBay,’’ cyanide was among the poisons advertised as available for sale in searches of the online auction web site over the 10-month period from May 2003 to February 2004.4 The perpetrator in the 2003 cyanide murder of a Baltimore teenager obtained cyanide over the Internet from a chemical and laboratory-supply company.5,6 The potential availability of
JOURNAL OF EMERGENCY NURSING
S1
CYANIDE SUPPLEMENT/Koschel
cyanide to anyone who can access the Internet gives unprecedented ease of access to the poison. Another heightened risk of cyanide is associated with inadvertent exposure to it as a combustion product in fire smoke. Today in the United States, smoke inhalation, rather than purposeful use of cyanide to inf lict harm, is the most common cause of acute cyanide poisoning.7,8 Cyanide is generated by the burning of carbon- and nitrogencontaining substances. Although cyanide substrates have always been common in occupied structures, they are becoming more plentiful with people’s increasing reliance on synthetics, which are particularly rich cyanide substrates. Substances such as plastic, polyurethane, and nylon can produce large quantities of cyanide when burned. Partly because of people’s increasing reliance on the nitrogen- and carbon-containing products of the polymer industry, the risk of human exposure to cyanide in the structural fire is arguably greater than ever before. This risk is illustrated by a press report of 5 firefighters who tested positive for cyanide poisoning after fighting a fire at a Providence, Rhode Island, restaurant in March, 2006.9 A very large amount of insulation made of Styrofoam, a cyanide substrate, burned during the fire. Cyanide, this old enemy with heightened risks, should be a topic of importance to emergency nurses. Among the first health care professionals to administer care to victims of poisoning, emergency nurses can play a pivotal role in the recognition and treatment of acute cyanide poisoning. This supplement discusses current understanding of the causes and consequences of acute cyanide poisoning and its recognition and clinical management. Sources of human exposure to cyanide are numerous. In his article, ‘‘Cyanide: Sources, Perceptions, and Risks,’’ Captain Rob Schnepp, Hazardous Materials Specialist with the Alameda County Fire Department, discusses both wellrecognized and lesser-known sources of acute exposure to cyanide. He describes recent data suggesting that cyanide is often as important as carbon monoxide as a toxicant in fire smoke. He also considers current concern about the threat of cyanide exposure in a terrorist attack. Cyanide is among the most rapidly acting and lethal of poisons—factors that make its recognition and management particularly challenging. Dr. Lewis Nelson of the New York City Poison Control Center summarizes the
S2
mechanisms of cyanide toxicity in his article, ‘‘Acute Cyanide Toxicity: Mechanisms and Manifestations.’’ Nelson relates the cellular and tissue effects of cyanide to the clinical manifestations of acute cyanide poisoning. Understanding how cyanide’s physiologic effects bring about specific clinical manifestations is helpful in the recognition of acute cyanide poisoning. The articles ‘‘Recognition and Treatment of Acute Cyanide Poisoning’’ by Dr. Stephen W. Borron of the University of Texas Health Science Center and ‘‘Management of the Cyanide-Poisoned Patient’’ by this author discuss the recognition and treatment of acute cyanide poisoning from a practical perspective. These articles cover all phases of care including prehospital, emergency department, and continuing care. Emergency nurses regardless of specialty—whether prehospital, f light, pediatric, trauma, triage, or advanced practice—may face the clinical challenge of treating the patient poisoned with cyanide. Effective care of the cyanidepoisoned patient by emergency nurses can save lives. The information in this supplement provides the emergency nurse with an increased awareness and knowledge base to reduce death and injury from cyanide poisoning. REFERENCES 1. Gracia R. Cyanide. In: Keyes DC, editor. Medical response to terrorism: preparedness and clinical practice. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 26-37. 2. Eckstein M. Cyanide as a chemical terrorism weapon. JEMS 2004; 29(suppl):22-31. 3. Sauer SW, Keim ME. Hydroxocobalamin: improved public health readiness for cyanide disasters. Ann Emerg Med 2001;37: 635-41. 4. Cantrell FL. Look what I found! Poison hunting on eBay. Clin Toxicol 2005;43:375-9. 5. Stewart K. Chemical company investigated. Louisville CourierJournal, March 26, 2006. 6. Peddy SB, Rigby MR, Shaffner DH. Acute cyanide poisoning. Pediatr Crit Care Med 2006;7:79-82. 7. Walsh DW, O’Brien DJ, Arnold JL. Cyanide poisoning: not just a HAZMAT issue. fireEMS, September 2004. Available from URL: fe.pennnet.com/Articles/Article_Display.cfm?Section= Articles&ARTICLE_ID=212520&VERSION_NUM=1&p=71. Accessed December 5, 2005. 8. Walsh DW, Eckstein M. Hydrogen cyanide in fire smoke: an under appreciated threat. Emerg Med Serv 2004;33:160-63. 9. Anonymous. Providence firefighters treated for exposure to cyanide. Available from URL: www.boston.com/news/local/rhode_ island/articles/2006/03/24/providence_firefighters_treated_for_ exposure_to_cyanide/. Accessed March 28, 2006.
JOURNAL OF EMERGENCY NURSING
32:4S
August 2006