- Email: [email protected]
Cyanide: Sources, Perceptions, and Risks
CYANIDE SUPPLEMENT
Cyanide: Sources, Perceptions, and Risks
Author: Robert Schnepp, EMT-P, Modesto, Calif
Robert Schnepp, Hazardous Materials Specialist, Alameda County Fire Department, Alameda County, Calif. For correspondence, write: Robert Schnepp, EMT-P, 1425 Inspiration Drive, Modesto, CA 95357; E-mail: [email protected]. J Emerg Nurs 2006;32:S3-7. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.05.008
C
yanide is found in many forms—as simple and complex cyanide compounds, cyanogens, cyanide ions, and nitrile compounds and can occur as solids, liquids, or gases. Regardless of the origin and use of cyanide compounds, the threat of exposure from accidental and intentional poisonings exists. Through understanding the sources of cyanide poisoning and the array of circumstances under which it can occur, emergency nurses are better able to use contextual information to aid in the recognition of acute cyanide poisoning. This study discusses sources of cyanide likely to cause human exposure.
Natural and Manufactured Sources
Cyanide comes from both natural and manufactured sources (Table 1)1,2 More than 2650 plant species can produce cyanide depending on their preparation or through digestion. The largest risk of exposure, however, comes from manufactured sources. An estimated 1.838 billion pounds of cyanide was produced and used in 2004 in the United States.3 Manufacture of products used in building construction and transportation vehicle interiors as well as residential and commercial building interiors and furnishings accounts for the majority of the use of cyanide. Manufactured products using cyanide in their production include nylon, rayon, polyvinyl chloride, modacrylic, polyurethane foam, polyester wadding, neoprene foam, rubber, plastics, Styrofoam, insulation, and adhesive resins. Cyanide is a Toxicant in Fire Smoke
Annual statistics compiled by the National Fire Protection Association and the United States Fire Administration
August 2006
32:4S
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CYANIDE SUPPLEMENT/Schnepp
TABLE 1
Potential causes of acute cyanide poisoning1,2 . . . . . . . . .
Inhalation of fire smoke Accidental ingestion Occupational exposure Industrial incident Homicide attempt Suicide attempt Terrorism Ingestion of cyanogenic plants Ingestion of cyanogenic drugs
consistently show smoke inhalation to be a common source of fire-related death and injury.4 Fire smoke is a mixture of small particles of unburned fuel and asphyxiant and irritant gases from the chemical breakdown of its sources. With the advent of plastics and other synthetic materials, the nature of the typical residential structure fire has changed. A room-and-contents fire in an average singlefamily dwelling develops faster and burns hotter than a similar fire 20 years ago because of the prevalence of highly combustible synthetic substances including plastic, urethane foam, fiberglass insulation, nylon, rayon, and polyester. Additionally, a modern-day structure fire produces multiple toxic gases including carbon monoxide, formaldehyde and acetaldehyde, sulfur compounds, various oxides of nitrogen, hydrogen chloride, and cyanide.
Industrial accidents or transportation-related mishaps pose a risk of exposing large numbers of people to cyanide. A series of studies conducted by the Swedish National Testing and Research Institute, illustrates the chemical process by which cyanide compounds are formed during combustion.5 The studies show that combustion chemistry is quite complicated and greatly inf luenced by the amount of oxygen available to the combustion process. Recycling of combustion products to the fire increases the formation of both hydrogen cyanide and carbon monoxide. If the burning materials contain nitrogen, as do many plastics and
S4
synthetics, hydrogen cyanide is likely to be produced. Anyone breathing fire smoke will be exposed to some amount of cyanide as well as the other toxic byproducts of combustion. Hydrogen cyanide is a fire gas of particular interest to health care professionals who treat victims of smoke inhalation. Carbon monoxide has historically been viewed as the leading cause of death in smoke-inhalation fatalities. However, recent research in the United States and Europe suggests that cyanide, too, is an important cause of smokeinhalation morbidity and mortality.5-8 In several reports fire victims had sublethal blood concentrations of carbon monoxide in the presence of lethal blood concentrations of cyanide.9,10 Possibly, cyanide poisoning was the main cause of death in these victims. This finding does not minimize the importance of carbon monoxide in smokeinhalation morbidity and mortality. Rather, it underscores the need to recognize the probable presence of cyanide in smoke exposures. Recognition and management of acute cyanide poisoning in victims of smoke inhalation are discussed further elsewhere in this supplement.9,10 Cyanide is a Likely Terrorist Weapon
On May 4, 2004 in Houston, Texas, just before he was sentenced to federal prison for possessing a chemical weapon, William Krar again professed his innocence. The evidence, however, paints a different picture of William Krar. According to federal authorities, Krar and his 55-year-old common-law wife possessed a deadly arsenal of machine guns, remote-controlled explosive devices disguised as briefcases, more than 60 pipe bombs, and nearly 500,000 rounds of ammunition.11,12 The most worrisome part of the seized cache was not the pipe bombs or explosive briefcases; it was 800 grams of sodium cyanide found inside an ammunition container next to several bottles of hydrochloric and nitric acid with formulae for making chemical bombs. The potential sodium cyanide-acid mixture is similar to the combination used in the Nazi gas chambers and lethal enough, according to experts, to kill everyone inside a 30,000 squarefoot building. ‘‘There’s no reason for anyone to possess that type of device other than to kill people,’’ said Brit Featherston, a federal prosecutor on the case. ‘‘There’s
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international terrorism and domestic terrorism,’’ he explained, ‘‘but it’s all terrorism.’’13
Hydrogen cyanide is an important cause of smoke-inhalation morbidity and mortality. The Krar case illustrates a chilling reality: today’s terrorist cannot be easily typed and is capable of striking anywhere with any type of weapon. William Krar hid the components of his cyanide bomb in a public storage building in Noonday, Texas—a tiny farming town 100 miles southeast of Dallas. Fortunately, he was arrested before he used the bomb. Using cyanide as weapon is not a new idea. Cyanide continues to be an important part of terrorists’ arsenals as illustrated by several recent findings14: . Courtroom transcripts from the 1993 World Trade Center bombings indicate that terrorists planned to use cyanide in the attack. . At the time of the 1995 Tokyo subway attacks, precursors of cyanide were found in the subway bathrooms. . In 2002, British officials prevented al-Qaeda’s attempt to use cyanide gas to kill commuters on the London subway. . Also in 2002, a cyanide store in Paris was linked to three suspected al-Qaeda operatives. Documentation of al-Qaeda’s training in the generation and use of cyanide was found. Cyanide is considered an ideal chemical weapon that is plentiful and readily available.15 Because of its widespread use in industry and research laboratories, cyanide is widely transported, creating opportunities for theft, hijacking attempts, or other terrorist acts. Unlike many biologic or chemical weapons, cyanide requires no special skill to use. The dramatic presentation of cyanide poisoning, its lethality, and the difficulty in identifying its source during a terrorist incident contribute to the potential of cyanide to create panic, confusion, and social disruption. Moderate-to-high concentrations of cyanide can quickly kill most victims unless a cyanide antidote is rapidly administered. The ability of cyanide to cause
August 2006
32:4S
extensive lethality is illustrated by the 1978 mass suicide in Jonestown, Guyana, where more than 900 followers of Jim Jones died after drinking cyanide-spiked Kool-Aid, and the 1984 Bhopal, India, industrial accident that was responsible for as many as 5000 deaths from inhalation of methyl isocyanate and other cyanide compounds. Cyanide and Industry
Because cyanide is used in many industries, human exposure is possible in industrial or occupational accidents. Occupations with potential exposure to cyanide are listed in Table 2.3 Cyanide compounds used in industry include hydrogen cyanide, cyanogen chloride, cyanide salts containing sodium or potassium, gold and silver cyanide, and a host of other specialized cyanide compounds used in the production of plastics, pigments, and dyes (e.g., Prussian blue).16,17 The mining industry relies heavily on sodium cyanide to extract gold. Cyanide leaching, one of several gold extraction technologies in practice today, was promoted by the United States Bureau of Mines in the 1960s to replace mercury amalgamation, an older and less effective process of mining gold. Cyanide leaching involves spraying a sodium cyanide solution (approximately 250 to 500 parts per million) on piles of finely ground ore or waste rock. The microscopic gold in these piles (or tailings) forms a water-soluble compound with the cyanide. The cyanide solution is then passed over activated carbon to extract the gold. Leftover cyanide waste is stored in lined and covered ponds to prevent contact with humans, local animals, and birds. Worldwide, cyaniderelated accidents in the mining industry have resulted in deadly human exposures and environmental damage.
Cyanide is plentiful, readily available, requires no special skill to use, and can kill quickly—characteristics that make it an attractive terrorist weapon. Other industries such as plastics manufacturing, electroplating, metallurgy, leather tanning, photography, photoengraving, semiconductor fabrication, and pesticide/
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CYANIDE SUPPLEMENT/Schnepp
TABLE 2
Occupations with potential exposure to cyanide3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .
S6
Acid dippers Acrylate makers Acrylonitrile makers Adipic acid makers
.
Adiponitril makers Aircraft workers Almond flavor makers
.
Ammonium salt makers Art printing workers Blacksmiths Blast furnace workers Bone distillers Bronzers Browners Cadmium platers Case hardeners
.
Cellulose product treaters Cement makers Coal tar distillery workers Coke oven operators Cyanide workers Cyanogen makers Disinfectant makers Dye makers Electroplaters Executioners Exterminators Fertilizer makers Firefighters Fulminate mixers Fumigant makers Fumigators of fruit trees, apiaries, soil, ships, railway cars, warehouses, stored foods Galvanizers Gas purifiers Gas workers Gilders
.
. . .
. .
. . . . . . . .
. . . . . . . . . . . . . . . . . . . .
Gold extractors Gold refiners Heat treaters Hexamethylendiamine makers Hydrocyanic acid makers Hydrogen cyanide workers Insecticide and rodenticide makers Jewelers Laboratory technicians Metal cleaners Metal polishers Methacrylate makers Mirror silverers Mordanters Nylon makers Organic chemical synthesizers Oxalic acid makers Phosphoric acid makers Photoengravers Photographers Pigment makers Plastic workers Polish makers Rayon makers Rubber makers Silver extractors Silver refiners Solderers Steel carburizers Steel hardeners Steel galvanizers Tannery workers Temperers Tree sprayers White cyanide makers Zinc platers Zinkers
insecticide production either use or generate cyanide compounds during processing.16,17 Significant cyanide exposure is possible in any or all of these industrial settings or during transportation of cyanide for use in industry. A group of industrial chemicals known as nitriles (organic chemical compounds bonded to a cyanide group, CN-), commonly used in polystyrene manufacturing and biotechnology processes, warrants special attention from a health-and-safety standpoint. Once inside the body, these chemical compounds are metabolized by the liver and subsequently release cyanide into the body. Thus, the byproduct of nitrile metabolism rather than the nitrile itself causes toxicity. The secondary health effects from metabolized nitrile compounds may be delayed from 2 to 8 hours after initial exposure. Aliphatic nitriles including acetonitrile (also known as methyl cyanide), acrylonitrile, isobutyronitrile, and methyl acrylonitrile are the most toxic of the nitrile compounds. Conclusions
Main causes of acute cyanide poisoning include inhalation of fire smoke; accidental ingestion; occupational exposure; industrial incidents; homicide or suicide attempts; terrorism; and ingestion of cyanogenic substances. To lay people, cyanide poisoning may conjure thoughts of incidents that have received media attention: the Jonestown suicides; the massive release of methyl isocyanate at the Union Carbide plant in Bhopal, India; the 1982 poisoning of 7 Chicagoans with cyanide-tainted Tylenol capsules; the death of a Maryland teenager from drinking cyanide-laced Coca-Cola. Emergency nurses play an integral role in the recognition and management of cyanide poisoning in situations such as these—which, horrific as they are, are generally rare occurrences. Emergency nurses are more likely to encounter victims of cyanide poisoning from smoke inhalation, a lesspublicized but more common source of acute cyanide poisoning. For example, the unconscious 22-year-old victim of smoke inhalation from a structural fire should be viewed as a chemical exposure and possibly considered a candidate for antidotal treatment. Emergency nurses also must be prepared for the increasingly salient possibility of successful use of cyanide as a terrorist weapon.
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CYANIDE SUPPLEMENT/Schnepp
Acknowledgment The author acknowledges Jane Saiers, PhD, in writing this manuscript. Dr. Saiers’ and the author’s work on this manuscript was funded by EMD Pharmaceuticals.
REFERENCES 1. United States Department of Health, Education, and Welfare. National Institute for Occupational Safety and Health. Occupational exposure to hydrogen cyanide and cyanide salts. DHEW (NIOSH) Publication No. 77-108. October 1976. 2. Guidotti T. Acute cyanide poisoning in prehospital care: new challenges, new tools for intervention. Prehosp Disast Med 2006; 21:s40-8. 3. United States Department of Health and Human Services. Toxicological profile for cyanide. Agency for Toxic Substances and Disease Registry, September 2004. 4. Karter MJ Jr. Fire loss in the United States during 2004. Fire Analysis Research Division, National Fire Protection Association. September 2005; Quincy, MA. Available from URL: www. nfpa.org/assets/files/PDF/OS.fireloss.pdf. Accessed March 28, 2006. 5. Tuovinen H, Blomqvist P. Modeling of hydrogen cyanide formation in room fires. Brandforsk project 321-011. SP Swedish National Testing and Research Institute. SP Report 2003:10. Bor3s, Sweden, 2003. 6. Baud F, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 1991;325: 1761-6. 7. Alarie Y. Toxicity of fire smoke. Crit Rev Toxicol 2002;32:259-89. 8. Alsh DW. Cyanide: a ubiquitous product of combustion in modern fires. fireEMS 2005;May:6-11. 9. Koschel MJ. Management of the cyanide-poisoned patient. [Citation for accompanying supplement paper to be inserted when available.] 10. Borron SW. Recognition and treatment of acute cyanide poisoning. [Citation for accompanying supplement paper to be inserted when available.] 11. Anonymous. Man to be sentenced for cyanide possession. Houston Chronicle. 4 May 2004. Available from URL: www. chron.com/CDA/archives/archive.mpl?id=2004_3759824. Accessed March 28, 2006. 12. Anonymous. Media revolt: a manifesto. Available from URL: dneiwert.blogspot.com/2004_05_02_dneiwert_archive.html. 7 May 2004. Accessed March 28, 2006. 13. Anonymous. Cyanide, arsenal stirs domestic terror fear. 30 January 2004. Available from URL: www.cnn.com/2004/US/ Southwest/01/30/cyanide.probe.ap/. Accessed March 28, 2006. 14. Stewart C, Molino LN. Cyanide as a chemical weapon: a primer for emergency medical responders. Frontline First Responder 2004 October. 15. Eckstein M. Cyanide as a chemical terrorism weapon. JEMS 2004; 29:22-31. 16. Gossel TA, Bricker JD. Carbon monoxide, cyanide, and sulfide. Principles of clinical toxicology 3rd ed. New York: Raven Press, 1994. p. 109-34. 17. World Health Organization. Hydrogen cyanide and cyanides: human health aspects. Concise International Chemical Assessment Document 61. World Health Organization, Geneva, 2004.
August 2006
32:4S
JOURNAL OF EMERGENCY NURSING
S7
Cyanide: Sources, Perceptions, and Risks
Author: Robert Schnepp, EMT-P, Modesto, Calif
Robert Schnepp, Hazardous Materials Specialist, Alameda County Fire Department, Alameda County, Calif. For correspondence, write: Robert Schnepp, EMT-P, 1425 Inspiration Drive, Modesto, CA 95357; E-mail: [email protected]. J Emerg Nurs 2006;32:S3-7. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.05.008
C
yanide is found in many forms—as simple and complex cyanide compounds, cyanogens, cyanide ions, and nitrile compounds and can occur as solids, liquids, or gases. Regardless of the origin and use of cyanide compounds, the threat of exposure from accidental and intentional poisonings exists. Through understanding the sources of cyanide poisoning and the array of circumstances under which it can occur, emergency nurses are better able to use contextual information to aid in the recognition of acute cyanide poisoning. This study discusses sources of cyanide likely to cause human exposure.
Natural and Manufactured Sources
Cyanide comes from both natural and manufactured sources (Table 1)1,2 More than 2650 plant species can produce cyanide depending on their preparation or through digestion. The largest risk of exposure, however, comes from manufactured sources. An estimated 1.838 billion pounds of cyanide was produced and used in 2004 in the United States.3 Manufacture of products used in building construction and transportation vehicle interiors as well as residential and commercial building interiors and furnishings accounts for the majority of the use of cyanide. Manufactured products using cyanide in their production include nylon, rayon, polyvinyl chloride, modacrylic, polyurethane foam, polyester wadding, neoprene foam, rubber, plastics, Styrofoam, insulation, and adhesive resins. Cyanide is a Toxicant in Fire Smoke
Annual statistics compiled by the National Fire Protection Association and the United States Fire Administration
August 2006
32:4S
JOURNAL OF EMERGENCY NURSING
S3
CYANIDE SUPPLEMENT/Schnepp
TABLE 1
Potential causes of acute cyanide poisoning1,2 . . . . . . . . .
Inhalation of fire smoke Accidental ingestion Occupational exposure Industrial incident Homicide attempt Suicide attempt Terrorism Ingestion of cyanogenic plants Ingestion of cyanogenic drugs
consistently show smoke inhalation to be a common source of fire-related death and injury.4 Fire smoke is a mixture of small particles of unburned fuel and asphyxiant and irritant gases from the chemical breakdown of its sources. With the advent of plastics and other synthetic materials, the nature of the typical residential structure fire has changed. A room-and-contents fire in an average singlefamily dwelling develops faster and burns hotter than a similar fire 20 years ago because of the prevalence of highly combustible synthetic substances including plastic, urethane foam, fiberglass insulation, nylon, rayon, and polyester. Additionally, a modern-day structure fire produces multiple toxic gases including carbon monoxide, formaldehyde and acetaldehyde, sulfur compounds, various oxides of nitrogen, hydrogen chloride, and cyanide.
Industrial accidents or transportation-related mishaps pose a risk of exposing large numbers of people to cyanide. A series of studies conducted by the Swedish National Testing and Research Institute, illustrates the chemical process by which cyanide compounds are formed during combustion.5 The studies show that combustion chemistry is quite complicated and greatly inf luenced by the amount of oxygen available to the combustion process. Recycling of combustion products to the fire increases the formation of both hydrogen cyanide and carbon monoxide. If the burning materials contain nitrogen, as do many plastics and
S4
synthetics, hydrogen cyanide is likely to be produced. Anyone breathing fire smoke will be exposed to some amount of cyanide as well as the other toxic byproducts of combustion. Hydrogen cyanide is a fire gas of particular interest to health care professionals who treat victims of smoke inhalation. Carbon monoxide has historically been viewed as the leading cause of death in smoke-inhalation fatalities. However, recent research in the United States and Europe suggests that cyanide, too, is an important cause of smokeinhalation morbidity and mortality.5-8 In several reports fire victims had sublethal blood concentrations of carbon monoxide in the presence of lethal blood concentrations of cyanide.9,10 Possibly, cyanide poisoning was the main cause of death in these victims. This finding does not minimize the importance of carbon monoxide in smokeinhalation morbidity and mortality. Rather, it underscores the need to recognize the probable presence of cyanide in smoke exposures. Recognition and management of acute cyanide poisoning in victims of smoke inhalation are discussed further elsewhere in this supplement.9,10 Cyanide is a Likely Terrorist Weapon
On May 4, 2004 in Houston, Texas, just before he was sentenced to federal prison for possessing a chemical weapon, William Krar again professed his innocence. The evidence, however, paints a different picture of William Krar. According to federal authorities, Krar and his 55-year-old common-law wife possessed a deadly arsenal of machine guns, remote-controlled explosive devices disguised as briefcases, more than 60 pipe bombs, and nearly 500,000 rounds of ammunition.11,12 The most worrisome part of the seized cache was not the pipe bombs or explosive briefcases; it was 800 grams of sodium cyanide found inside an ammunition container next to several bottles of hydrochloric and nitric acid with formulae for making chemical bombs. The potential sodium cyanide-acid mixture is similar to the combination used in the Nazi gas chambers and lethal enough, according to experts, to kill everyone inside a 30,000 squarefoot building. ‘‘There’s no reason for anyone to possess that type of device other than to kill people,’’ said Brit Featherston, a federal prosecutor on the case. ‘‘There’s
JOURNAL OF EMERGENCY NURSING
32:4S
August 2006
CYANIDE SUPPLEMENT/Schnepp
international terrorism and domestic terrorism,’’ he explained, ‘‘but it’s all terrorism.’’13
Hydrogen cyanide is an important cause of smoke-inhalation morbidity and mortality. The Krar case illustrates a chilling reality: today’s terrorist cannot be easily typed and is capable of striking anywhere with any type of weapon. William Krar hid the components of his cyanide bomb in a public storage building in Noonday, Texas—a tiny farming town 100 miles southeast of Dallas. Fortunately, he was arrested before he used the bomb. Using cyanide as weapon is not a new idea. Cyanide continues to be an important part of terrorists’ arsenals as illustrated by several recent findings14: . Courtroom transcripts from the 1993 World Trade Center bombings indicate that terrorists planned to use cyanide in the attack. . At the time of the 1995 Tokyo subway attacks, precursors of cyanide were found in the subway bathrooms. . In 2002, British officials prevented al-Qaeda’s attempt to use cyanide gas to kill commuters on the London subway. . Also in 2002, a cyanide store in Paris was linked to three suspected al-Qaeda operatives. Documentation of al-Qaeda’s training in the generation and use of cyanide was found. Cyanide is considered an ideal chemical weapon that is plentiful and readily available.15 Because of its widespread use in industry and research laboratories, cyanide is widely transported, creating opportunities for theft, hijacking attempts, or other terrorist acts. Unlike many biologic or chemical weapons, cyanide requires no special skill to use. The dramatic presentation of cyanide poisoning, its lethality, and the difficulty in identifying its source during a terrorist incident contribute to the potential of cyanide to create panic, confusion, and social disruption. Moderate-to-high concentrations of cyanide can quickly kill most victims unless a cyanide antidote is rapidly administered. The ability of cyanide to cause
August 2006
32:4S
extensive lethality is illustrated by the 1978 mass suicide in Jonestown, Guyana, where more than 900 followers of Jim Jones died after drinking cyanide-spiked Kool-Aid, and the 1984 Bhopal, India, industrial accident that was responsible for as many as 5000 deaths from inhalation of methyl isocyanate and other cyanide compounds. Cyanide and Industry
Because cyanide is used in many industries, human exposure is possible in industrial or occupational accidents. Occupations with potential exposure to cyanide are listed in Table 2.3 Cyanide compounds used in industry include hydrogen cyanide, cyanogen chloride, cyanide salts containing sodium or potassium, gold and silver cyanide, and a host of other specialized cyanide compounds used in the production of plastics, pigments, and dyes (e.g., Prussian blue).16,17 The mining industry relies heavily on sodium cyanide to extract gold. Cyanide leaching, one of several gold extraction technologies in practice today, was promoted by the United States Bureau of Mines in the 1960s to replace mercury amalgamation, an older and less effective process of mining gold. Cyanide leaching involves spraying a sodium cyanide solution (approximately 250 to 500 parts per million) on piles of finely ground ore or waste rock. The microscopic gold in these piles (or tailings) forms a water-soluble compound with the cyanide. The cyanide solution is then passed over activated carbon to extract the gold. Leftover cyanide waste is stored in lined and covered ponds to prevent contact with humans, local animals, and birds. Worldwide, cyaniderelated accidents in the mining industry have resulted in deadly human exposures and environmental damage.
Cyanide is plentiful, readily available, requires no special skill to use, and can kill quickly—characteristics that make it an attractive terrorist weapon. Other industries such as plastics manufacturing, electroplating, metallurgy, leather tanning, photography, photoengraving, semiconductor fabrication, and pesticide/
JOURNAL OF EMERGENCY NURSING
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CYANIDE SUPPLEMENT/Schnepp
TABLE 2
Occupations with potential exposure to cyanide3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .
S6
Acid dippers Acrylate makers Acrylonitrile makers Adipic acid makers
.
Adiponitril makers Aircraft workers Almond flavor makers
.
Ammonium salt makers Art printing workers Blacksmiths Blast furnace workers Bone distillers Bronzers Browners Cadmium platers Case hardeners
.
Cellulose product treaters Cement makers Coal tar distillery workers Coke oven operators Cyanide workers Cyanogen makers Disinfectant makers Dye makers Electroplaters Executioners Exterminators Fertilizer makers Firefighters Fulminate mixers Fumigant makers Fumigators of fruit trees, apiaries, soil, ships, railway cars, warehouses, stored foods Galvanizers Gas purifiers Gas workers Gilders
.
. . .
. .
. . . . . . . .
. . . . . . . . . . . . . . . . . . . .
Gold extractors Gold refiners Heat treaters Hexamethylendiamine makers Hydrocyanic acid makers Hydrogen cyanide workers Insecticide and rodenticide makers Jewelers Laboratory technicians Metal cleaners Metal polishers Methacrylate makers Mirror silverers Mordanters Nylon makers Organic chemical synthesizers Oxalic acid makers Phosphoric acid makers Photoengravers Photographers Pigment makers Plastic workers Polish makers Rayon makers Rubber makers Silver extractors Silver refiners Solderers Steel carburizers Steel hardeners Steel galvanizers Tannery workers Temperers Tree sprayers White cyanide makers Zinc platers Zinkers
insecticide production either use or generate cyanide compounds during processing.16,17 Significant cyanide exposure is possible in any or all of these industrial settings or during transportation of cyanide for use in industry. A group of industrial chemicals known as nitriles (organic chemical compounds bonded to a cyanide group, CN-), commonly used in polystyrene manufacturing and biotechnology processes, warrants special attention from a health-and-safety standpoint. Once inside the body, these chemical compounds are metabolized by the liver and subsequently release cyanide into the body. Thus, the byproduct of nitrile metabolism rather than the nitrile itself causes toxicity. The secondary health effects from metabolized nitrile compounds may be delayed from 2 to 8 hours after initial exposure. Aliphatic nitriles including acetonitrile (also known as methyl cyanide), acrylonitrile, isobutyronitrile, and methyl acrylonitrile are the most toxic of the nitrile compounds. Conclusions
Main causes of acute cyanide poisoning include inhalation of fire smoke; accidental ingestion; occupational exposure; industrial incidents; homicide or suicide attempts; terrorism; and ingestion of cyanogenic substances. To lay people, cyanide poisoning may conjure thoughts of incidents that have received media attention: the Jonestown suicides; the massive release of methyl isocyanate at the Union Carbide plant in Bhopal, India; the 1982 poisoning of 7 Chicagoans with cyanide-tainted Tylenol capsules; the death of a Maryland teenager from drinking cyanide-laced Coca-Cola. Emergency nurses play an integral role in the recognition and management of cyanide poisoning in situations such as these—which, horrific as they are, are generally rare occurrences. Emergency nurses are more likely to encounter victims of cyanide poisoning from smoke inhalation, a lesspublicized but more common source of acute cyanide poisoning. For example, the unconscious 22-year-old victim of smoke inhalation from a structural fire should be viewed as a chemical exposure and possibly considered a candidate for antidotal treatment. Emergency nurses also must be prepared for the increasingly salient possibility of successful use of cyanide as a terrorist weapon.
JOURNAL OF EMERGENCY NURSING
32:4S
August 2006
CYANIDE SUPPLEMENT/Schnepp
Acknowledgment The author acknowledges Jane Saiers, PhD, in writing this manuscript. Dr. Saiers’ and the author’s work on this manuscript was funded by EMD Pharmaceuticals.
REFERENCES 1. United States Department of Health, Education, and Welfare. National Institute for Occupational Safety and Health. Occupational exposure to hydrogen cyanide and cyanide salts. DHEW (NIOSH) Publication No. 77-108. October 1976. 2. Guidotti T. Acute cyanide poisoning in prehospital care: new challenges, new tools for intervention. Prehosp Disast Med 2006; 21:s40-8. 3. United States Department of Health and Human Services. Toxicological profile for cyanide. Agency for Toxic Substances and Disease Registry, September 2004. 4. Karter MJ Jr. Fire loss in the United States during 2004. Fire Analysis Research Division, National Fire Protection Association. September 2005; Quincy, MA. Available from URL: www. nfpa.org/assets/files/PDF/OS.fireloss.pdf. Accessed March 28, 2006. 5. Tuovinen H, Blomqvist P. Modeling of hydrogen cyanide formation in room fires. Brandforsk project 321-011. SP Swedish National Testing and Research Institute. SP Report 2003:10. Bor3s, Sweden, 2003. 6. Baud F, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 1991;325: 1761-6. 7. Alarie Y. Toxicity of fire smoke. Crit Rev Toxicol 2002;32:259-89. 8. Alsh DW. Cyanide: a ubiquitous product of combustion in modern fires. fireEMS 2005;May:6-11. 9. Koschel MJ. Management of the cyanide-poisoned patient. [Citation for accompanying supplement paper to be inserted when available.] 10. Borron SW. Recognition and treatment of acute cyanide poisoning. [Citation for accompanying supplement paper to be inserted when available.] 11. Anonymous. Man to be sentenced for cyanide possession. Houston Chronicle. 4 May 2004. Available from URL: www. chron.com/CDA/archives/archive.mpl?id=2004_3759824. Accessed March 28, 2006. 12. Anonymous. Media revolt: a manifesto. Available from URL: dneiwert.blogspot.com/2004_05_02_dneiwert_archive.html. 7 May 2004. Accessed March 28, 2006. 13. Anonymous. Cyanide, arsenal stirs domestic terror fear. 30 January 2004. Available from URL: www.cnn.com/2004/US/ Southwest/01/30/cyanide.probe.ap/. Accessed March 28, 2006. 14. Stewart C, Molino LN. Cyanide as a chemical weapon: a primer for emergency medical responders. Frontline First Responder 2004 October. 15. Eckstein M. Cyanide as a chemical terrorism weapon. JEMS 2004; 29:22-31. 16. Gossel TA, Bricker JD. Carbon monoxide, cyanide, and sulfide. Principles of clinical toxicology 3rd ed. New York: Raven Press, 1994. p. 109-34. 17. World Health Organization. Hydrogen cyanide and cyanides: human health aspects. Concise International Chemical Assessment Document 61. World Health Organization, Geneva, 2004.
August 2006
32:4S
JOURNAL OF EMERGENCY NURSING
S7