Smoke Inhalation & Hydrogen Cyanide Poisoning

SMOKE INHALATION & HYDROGEN CYANIDE POISONING The Danger Posed to Firefighters & Victims in Structure Fires CONTENTS

5 Hydrogen Cyanide Fire smoke’s silent killer BY KEN RIDDLE, DEPUTY CHIEF FIRE MARSHAL Smoke Inhalation & 6 Acute Cyanide Poisoning Hydrogen cyanide poisoning proves increasingly common in smoke-inhalation victims BY RICHARD ALCORTA, MD, FACEP Hydroxocobalamin: 18 Treatment for Smoke Inhalation-Associated Cyanide Poisoning SMOKE INHALATION & HYDROGEN CYANIDE POISONING Meeting the needs of fire victims A Jems Communications Supplement BY JEAN-LUC FORTIN, MD, M. RUTTIMAN, MD, Sponsored by EMD Pharmaceuticals L. DOMANSKI, MD, & J.J. KOWALSKI, MD Publisher/General Manager Jeff Berend Senior Editor Keri Losavio Cyanide as a Chemical Supplement Editor Jennifer Doyle Supplement Art Director Daniel DiPinto 22 Terrorism Weapon Production Manager Tim Francis BY MARC ECKSTEIN, MD, FACEP Smoke Inhalation & Hydrogen Cyanide Poisoning is an edi- torial supplement sponsored by EMD Pharmaceuticals and published by Jems Communications, 525 B Street, Suite 1900, San Diego, CA 92101-4495; 800/266-5367 (fed. ID #13-935377). Copyright 2004 Elsevier Inc. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. Subscription information: To subscribe to a Jems Communications publication, visit www.jems.com. Advertising information: Rates are available on request. Contact Jems Communications Advertising Department at 525 B Street, Suite 1900, San Diego, CA 92101-4495; 800/266-5367.

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 3 HYDROGEN CYANIDE Fire Smoke’s Silent Killer

TREATMENT FOR SMOKE ommend using, and discusses how INHALATION in the United States important rapid treatment is to improv- has not changed much during the past ing chances for survival. several years: We remove the victim In the second presentation, Jean-Luc from the source, provide high-flow Fortin, MD, chief of medicine for the 100% oxygen and assist with ventila- Third Division of the Paris (France) Fire tion, if needed. Responding EMS per- Brigade, provides data on an alternative sonnel and firefighters are primarily cyanide antidote that is currently avail- concerned with carbon monoxide poi- able in Europe. Hydroxocobalamin is soning and hypoxia in smoke-inhala- routinely used in France to treat tion patients. However, hydrogen smoke-inhalation victims at the scene cyanide poisoning is an increasingly of fires. Dr. Fortin reviews data from a common byproduct of fire smoke in retrospective study of 81 smoke-inhala- structure fires, threatening both fire tion victims treated with hydroxocobal- victims and firefighters. Unfortunately, amin by the Paris Fire Brigade. The it is rarely treated in the United States, results are promising, with a 62.1% sur- and when it is, the current U.S. drug vival rate following hydroxocobalamin therapy for cyanide poisoning carries a administration as part of treatment for risk of actually doing more harm than cyanide poisoning and carbon monox- good. ide exposure. At the International Association of The final presenter, Marc Eckstein, Fire Chiefs EMS Section’s Fire-Rescue MD, medical director for the Los Deputy Chief Ken Riddle Med Conference in April, I served as Angeles Fire Department and an asso- the moderator for a panel of experts ciate professor of emergency medicine has more than 30 years’ experience who addressed the topic of cyanide at the University of Southern with emergency poisoning in smoke inhalation and California School of Medicine, discuss- services in both chemical terrorism. The presentations, es the intentional use of cyanide as an the private and compiled in this special issue, are agent of war and terror. He notes that public sectors. A designed to educate emergency cyanide is plentiful, readily available member of the Las Vegas Department of response professionals on the risks of and does not require special expertise Fire & Rescue for 25 years, Riddle cur- cyanide poisoning, as well as the treat- to use. Dr. Eckstein also indicates that rently serves as the city’s fire marshal. ment options. if hydroxocobalamin becomes avail- As a chief officer for the past 10 years, In the first article, Richard Alcorta, able in the United States, cyanide poi- he has been responsible for the opera- MD, medical director at the Maryland soning may be successfully treated in a tions, administration and medical services Institute for Emergency Medical prehospital setting. divisions. While serving in those positions, he designed and developed several major Services System, notes that smoke Collectively, the presentations programs, including an ambulance inhalation causes 5,000–10,000 deaths provide a broad overview of cyanide transport program for the department. and more than 23,000 injuries—includ- poisoning and its treatment, both in Riddle was certified as a paramedic for ing 5,000 firefighters—in the United conjunction with smoke-inhalation several years and also served as a flight States annually. Dr. Alcorta presents exposure and as an agent of chemical medic. An author and frequent speaker data from several studies revealing terrorism. I believe you will find the on fire-based EMS issues, he is the elevated cyanide concentrations in articles extremely informative and immediate-past chair of the International smoke-inhalation victims, highlighting timely. Armed with this knowledge, I Association of Fire Chiefs EMS Section the direct relationship between cyanide am optimistic that we can eventually and the past president of the Southern blood concentrations and probability of reduce the significant number of Nevada Fire Chiefs Association. Riddle death, and indicating that cyanide and smoke-inhalation deaths experienced continues to serve as the conference manager for the EMS Section’s Fire- carbon monoxide enhance the toxic each year in this country, as well as Rescue Med Conference, held annually in effects of one another. He also reviews enhance our level of emergency pre- Las Vegas. the current treatment for smoke inhala- paredness for the potential use of tion, which some authorities do not rec- cyanide in chemical terrorism.

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 5 SMOKESMOKE INHALATIONINHALATION && ACUTEACUTE CYANIDECYANIDE POISONINGPOISONING Hydrogen cyanide poisoning proves increasingly common in smoke-inhalation victims BY RICHARD ALCORTA, MD, FACEP The family had gone to bed only two hours before the fire started. A space heater in the living room ignited a sofa cushion, which smoldered for a period of time, emitting toxic gases even before the flames appeared. Within minutes after flames appeared, the fire spread upward from the burning sofa cush- ions and ignited first the draperies, then the ceiling. As the fire gained force, toxic smoke filled the room and entered the hallway. The smoke detector located down the hall finally activated and awakened the family. Meanwhile, a neighbor saw the flames while he was walking his dog and called 9-1-1. The fire’s heat and its dense black smoke prevented the family from exiting via the stairs. When firefighters arrived within four minutes of the 9-1-1 call, they had to rescue the three victims through a second-story window. All were found huddled close to the window, disoriented or unconscious, with soot in their noses and mouths. The mother and four-year- old boy were given oxygen and transported to a hospital where they survived. The father, who had rushed into the hall and into his son’s room in an attempt to rescue him, went into full respiratory arrest. He had only 10% burns on his face and hands, but his condition, which initially appeared to stabilize, rapidly deteriorated en route to the hospital, despite 100% oxygen and supportive care. He died without regaining consciousness.

EMERGENCY medical and fire- toxicity that EMS and fire profes- rescue professionals tend to sionals will encounter. equate cyanide poisoning with Smoke inhalation is an impor- The JEMS continuing education program is coordinated by the accidental or intentional inges- tant but often overlooked cause of Center for Emergency Medicine, Pittsburgh, and the University of Pittsburgh, School of Health and Rehabilitation Sciences. tion. However, cyanide toxicity cyanide poisoning. A substantial from smoke inhalation in a struc- body of evidence reveals that tural or an enclosed-space fire is cyanide can be as great a threat as the most likely cause of cyanide carbon monoxide in fire smoke.

6 JEMS COMMUNICATIONS Photo Glen E. Ellman

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 7 This article will discuss: Studies completed by the Objectives • Why cyanide poisoning is a National Institute of Standards and growing concern in the fire and Technology in conjunction with the List reasons for the increased • EMS communities; Fire Protection Research Foundation incidence of smoke inhalation- • The role of cyanide in smoke document a significant increase in associated cyanide poisoning. inhalation-associated morbidi- toxic gases in smoke immediately • Determine the role of cyanide ty and mortality as evidenced before flashover occurs, as well as 2 in smoke inhalation-associated by two prospective studies— after flashover. Conditions of high a 2002 meta-analysis of fire temperature and low oxygen pro- morbidity and mortality. victim studies and animal mote degradation of synthetics, • Describe the management of research on cyanide-related which release hydrogen cyanide and smoke inhalation-associated incapacitation; and other toxic gases. cyanide poisonings. • The factors involved in the management of smoke inhalation- FIRE SMOKE associated cyanide poisoning— Smoke is composed of particulate its mechanism, manifestations, matter; heated gases, including irri- recognition and treatment. tants, such as hydrochloric acid, sulfur dioxide and ammonia; SMOKE TOXICITY asphyxiates, such as carbon diox- Smoke inhalation is a more com- ide; and toxins, such as hydrogen mon source of fire-related mortality sulfide and hydrogen cyanide. than burns. It causes 5,000–10,000 The constituents of smoke vary deaths annually in the United States from fire to fire and from one loca- and more than 23,000 injuries, tion to another in a given fire, including approximately 5,000 fire- depending on such factors as the fighter injuries. In fact, the United composition of the burning material, States has one of the highest fire- the rate of burning, the absolute tem- death rates among industrialized perature and the ambient oxygen countries.1 level. However, carbon monoxide and Smoke toxicity is an increasing hydrogen cyanide are very likely to concern, particularly in the fire be two of the most prevalent gases.3 service, because the industrial products used today are changing. Over the past two decades, we’ve seen a Sources of Cyanide shift away from woods and natural in Fire Smoke materials toward lighter construction materials, synthetics and petro- Natural Synthetic chemical-based materials. These substances substances materials ignite and burn two to • Wool • Plastics three times hotter and faster than • Silk • Other conventional materials and, when • Cotton polymers heated, emit a gas or smoke that will • Paper Cyanide toxicity also ignite two to three times faster from smoke and burn two to three times hotter than gas or smoke emitted from con- Hydrogen cyanide, the gaseous inhalation in a ventional materials. form of cyanide, is generated by the structural or These materials result in more combustion of nitrogen- and carbon- fires reaching flashover and a short- containing substances, including enclosed-space er time per fire between ignition and wool, silk, cotton and paper, as well fire is the most flashover. Consequently, firefighters as synthetic substances, such as have less time to gain control of a plastics and other polymers. Because likely cause of fire. Smoke-inhalation victims have of our extensive reliance on the cyanide toxicity less time to escape and are more polymer industry’s nitrogen- and likely to be incapacitated from the carbon-containing products, these that EMS & fire toxic smoke, thereby increasing the hydrogen cyanide substrates are professionals risk of other injuries, such as thermal ubiquitous in occupied structures. injuries. More effective prehospital Hydrogen cyanide is likely to be will encounter. treatment will save lives. produced under burning conditions

8 JEMS COMMUNICATIONS of high temperature and low oxygen, both of which are characteristic of PARIS FIRE Study Conclusions closed-space fires. An enclosed • Cyanide and carbon • Cyanide poisoning may have space serves as a container for the monoxide were both impor- predominated over carbon toxic gases in smoke, such as hydro- tant determinants of smoke monoxide poisoning as a gen cyanide.4,5 inhalation-associated cause of death in some fire Our two greatest threats in fire morbidity and mortality; victims; and smoke are carbon monoxide poison- • Cyanide concentrations • Cyanide and carbon monox- ing, of which most of us are aware, were directly related to the ide may have potentiated the and cyanide poisoning, of which probability of death; toxic effects of one another. many are not aware. Both carbon monoxide and hydrogen cyanide are silent killers. Both agents are colorless and odorless, dulling their es altered mental status and confu- victim’s cognitive function and sion, possibly preventing the victims impairing the fight-or-flight response from escaping. while their victim is completely Several deaths occurred in victims unaware of their presence. whose blood cyanide and carbon monoxide levels were both in the KEY CYANIDE STUDIES nontoxic range.6 These deaths could Two prospective studies performed possibly be attributed to causes other in Paris, France, and Dallas County, than the two toxins. However, the Texas, elucidate cyanide’s contribu- deaths among individuals having tion to smoke inhalation-associated nontoxic cyanide and carbon monox- mortality.6,7 These studies were ide levels may also be explained by designed to assess cyanide’s role in the potentiation of either or both fire-related morbidity and mortality. compounds’ toxic effects. This possi- The researchers overcame many bility is consistent with previous other studies’ limitations by collect- reports of fire victims having sub- ing blood samples close to the time lethal concentrations of carbon of smoke exposure and measuring monoxide and no other apparent cyanide in survivors rather than cause of death.8,9 It is also consistent only in fatalities. with animal studies showing the syn- In the Paris study, the first medical squads to arrive on scene at res- idential fires in Paris collected blood Treatment for hydrogen cyanide poisoning must be administered as quickly as possible after exposure. Therefore, presumptive in dry heparin over the span of a diagnosis and empiric treatment prove necessary to save lives. year (1988–1989). The blood cyanide data compared 109 fire victims (66 survivors and 43 fatalities) with 114 control individuals (40 with drug intoxication, 29 with carbon monoxide poisoning [none fire-related] and 45 with major trauma). The results show that mean blood cyanide concentrations in both fire victims who survived (21.6 mol/L, or 0.58 mg/L) and in those who died (116.4 mol/L, or 3.14 mg/L) were significantly (p<0.001) higher than those in control subjects (5.0 mol/L, or 0.01 mg/L), and levels in victims who died were significantly higher than those in victims who survived. Clearly, all those who died had a very high or lethal level of cyanide, perhaps due to the fact that cyanide

affects the heart and brain and caus- Photo Glen E. Ellman

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 9 cyanide concentrations in the 144 DALLAS FIRE Study Conclusions smoke-inhalation victims who • Elevated cyanide concentra- • Cyanide poisoning may have arrived alive at the ED were lower tions were pervasive among predominated over carbon than concentrations in the 43 vic- smoke-inhalation victims; monoxide poisoning as a tims who were dead on arrival (0.65 mg/L versus 2.15 mg/L). Of the 144 • Cyanide concentrations were cause of death in some fire patients who were alive when they directly related to the proba- victims. arrived at the ED, 12 had blood bility of death; and cyanide concentrations exceeding 1 mg/L, the lower limit of the range ergistic lethality of cyanide and car- defined as potentially lethal in this bon monoxide in the absence of study. Of these 12 patients, eight changes in blood concentrations.10 died. None of them had blood car- The Dallas County study assessed boxyhemoglobin (HbCO) concen- two groups of smoke-inhalation vic- trations suggesting carbon monox- tims over the same two-year period. ide as the cause of death (e.g., ≥50%). One group comprised 144 smoke- Although some of the patients who inhalation patients who were alive died had extensive burns that may at the time of initial evaluation in have contributed to death, three of the University of Texas Health them had ≤4% total body surface Science Center emergency depart- area burn.6 ment (ED). The second group com- These data are consistent with prised 43 individuals who were dead the results of the Paris study in on arrival at the Dallas County med- showing pervasive elevated cyanide ical examiner’s office. concentrations and a direct relation- The results show that mean blood ship between blood cyanide concentration and probability of death and in suggesting that cyanide poisoning may predominate over carbon Glossary monoxide poisoning as a cause of • Asphyxiate: A gas that is non- of a growing fire to a fully death in some fire victims. It is clear toxic but will displace oxygen developed fire. The rapid transi- that every victim metabolizes from the atmosphere, thus caus- tion to a state of total surface cyanide differently—some better ing a life-threatening environ- involvement in a fire of than others. For those who do not ment due to a lack of oxygen. combustible materials within a metabolize it well, it remained in compartment. their system and was apparently Carboxyhemoglobin (HbCO): • compounded by carbon monoxide, The laboratory measurable • Histo-toxin: A cellular poison or leading to their deaths. A limited component of blood that is the a substance that has a direct amount of cyanide is converted to bound percent of hemoglobin poisonous effect at the cellular byproducts through the sulfur trans- with carbon monoxide. Carbon (histo) level. The substance can ferase/rhodanese enzymes and the monoxide once attached to inhibit cellular respiration/ availability of sulfur donor com- hemoglobin prevents oxygen metabolism. pounds. Patients with existing liver from binding to those sites on Pyrolysis: A form of incinera- • disease or inherent limitation of the hemoglobin. tion that chemically decomposes these enzymes will have reduced organic materials by heat in the • Flashover: In a compartment clearance and increased toxicity. fire there can come a stage in absence of oxygen or is the decomposition/ transformation which the total thermal radia- 2002 META-ANALYSIS of a chemical compound tion from the fire plume, hot OF FIRE DEATHS caused by heat. gases and hot compartment Results of a 2002 meta-analysis of boundaries causes the genera- • Toxin: A poisonous substance fire casualty databases suggest that tion of flammable products of that can be produced during cyanide poisoning is a significant and pyrolysis from all exposed com- metabolism or growth of an independent contributor to smoke- bustible surfaces within the organism, or produced by the inhalation deaths.11 In the meta- compartment. Given a source of combination/combustion of analysis, data from seven published ignition, this will result in the materials. studies in which blood cyanide con- sudden and sustained transition centrations were reanalyzed in a uni- form manner to facilitate compar-

10 JEMS COMMUNICATIONS isons between studies. In most of the studies measuring blood cyanide, HbCO (carboxyhemoglobin), which is formed by the union of carbon monoxide with hemoglobin and is a marker of carbon monoxide poisoning, was also measured. The results of the meta-analysis should be interpreted in the context of its limitations, including the retrospective data collection and analysis of many of the studies included in the meta-analysis, inconsistencies between studies in blood sampling methods, and timing and significant delays in some studies in analyzing blood samples. (Data from studies in which only carbon monoxide was measured were also reported in the meta-analysis but are not described here. In addition, data from a 1966 report that included blood cyanide Photo Glen E. Ellman measurements are not included Although poor tissue utilitization of oxygen in cyanide poisoning here because no details about the should theoretically render supplemental oxygen useless, study sample were described.) supportive care with administration of oxygen has proven The results show that, across effective in a number of poisonings. studies, significant proportions (33–87%) of fire victims had blood cyanide levels of at least 1 mg/L, val- 2002 META-ANALYSIS Conclusions ues above which are potentially Exposure to potentially In some fire incidents, ≥ • • lethal. Blood cyanide levels 3 mg/L lethal cyanide concentrations cyanide may have played were found in 5–46% of victims was frequent; a more important role in across studies. The percentage of • Coexposure to carbon causing death than carbon victims with potentially lethal levels monoxide. of carbon monoxide ranged from monoxide and cyanide 5–98% across studies. was frequent; and Cyanide perhaps played a greater role in mortality than carbon (median=1 mg/L), whereas only 5% of Hydrogen cyanide monoxide in two particular fires victims had HbCO levels exceeding considered in the meta-analysis: the 50% (median HbCO=33%). In this fire, is generated by Manchester aircraft fire at unlike the Manchester aircraft fire, the combustion Manchester International Airport in many of the victims were severely 1985 and the Dupont Plaza Hotel burned, and the relative contribu- of nitrogen- fire in San Juan, Puerto Rico, in tions of smoke inhalation and burns & carbon- 1986. Victims of the Manchester fire to their deaths are difficult to deter- were not severely burned and were mine. This caveat notwithstanding, containing determined to have died of smoke the results considered in aggregate substances, inhalation. The majority (87%) of the are consistent with the possibility 54 individuals who died had poten- that cyanide can sometimes be a including wool, tially lethal blood cyanide levels of more important determinant of silk, cotton & ≥1 mg/L (median=2.3 mg/L), where- smoke inhalation-associated mortali- as only 21% of victims had HbCO ty than carbon monoxide, which is paper, as well levels exceeding 50% (median usually regarded as the primary toxic as synthetic HbCO=39%). threat in fire smoke. Similarly, in the Dupont Plaza The results of the 2002 meta- substances, such Hotel fire, approximately half (48%) analysis show frequent exposure to as plastics & of the 53 victims had potentially potentially lethal concentrations of lethal blood cyanide levels of ≥1 mg/L cyanide, as well as coexposure to car- other polymers.

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 11 bon monoxide and cyanide in smoke- hydrogen cyanide. Cyanide inhalation victims. Consistent with Cyanide-exposed monkeys hyper- poisoning should the prospective Paris and Dallas ventilated and then rapidly lost con- be suspected in County studies, the meta-analysis sciousness at a rate dependent on the results suggest that, in some fire inci- concentration of exposure. A concen- any fire victim dents, cyanide may have played a tration of 200 parts per million (ppm) & greater role in causing death than was associated with rapid incapacita- may be carbon monoxide. tion but not with elevated blood particularly cyanide concentrations measured SUBLETHAL CYANIDE hours after exposure. The authors likely in CONCENTRATIONS suggest on the basis of these findings individuals Most assessments of cyanide poi- that cyanide in smoke can lead to soning in smoke-inhalation victims death indirectly via incapacitation, exposed to have attempted to define the role of which immobilizes the smoke-inhala- closed-space cyanide exposure in fire-related tion victim and permits more pro- & in those deaths. The role of sublethal con- longed exposure to potentially fatal fires centrations of cyanide in smoke concentrations of other toxins and with soot in the inhalation-associated morbidity and asphyxiates identified as the primary mouth or nose, mortality has not been systematical- cause of death.12 ly assessed in humans. Considered in aggregate, the altered mental Data from research in which blood cyanide findings in fire vic- status or monkeys were exposed to fumes tims support an important role of from the pyrolysis of polyacryloni- this toxin in smoke inhalation- hypotension. trile—a high-nitrogen polymer associated morbidity and mortality. used in fiber form for fabrics, Cyanide poisoning should be sus- upholstery covers, infill padding pected in any fire victim and may be and clothing—suggest that sub- particularly likely in individuals lethal levels of cyanide can cause exposed to closed-space fires and in rapid incapacitation that prevents those with soot in the mouth or efforts to escape toxic fumes. Under nose, altered mental status or thermal decomposition, approxi- hypotension.11,13 mately half of the mass of polyacry- lonitrile becomes available as SIGNS & SYMPTOMS Smoke inhalation-associated cyanide poisoning manifestations vary.In vic- Firefighters who respond to enclosed-space fires are tims with low inhaled-cyanide con- increasingly exposed to hydrogen cyanide, a byproduct of fire centrations or very recent exposure smoke from nitrogen- and carbon-containing materials used in to moderate or high concentrations, construction and furniture today. manifestations may include: • Faintness; • Flushing; • Anxiety; • Excitement; • Perspiration; • Vertigo; • Headache; • Drowsiness; • Tachypnea; • Dyspnea; and • Tachycardia.

In victims with moderate or high concentrations, manifestations may include: • Prostration; • Tremors; • Cardiac arrhythmia;

Photo Glen E. Ellman • Convulsions;

12 JEMS COMMUNICATIONS • Stupor; • Paralysis; • Coma; • Respiratory depression; • Respiratory arrest; and • Cardiovascular collapse.

Cyanide is a histo-toxin. It causes toxicity by deactivating the mechanism by which cells use oxygen. The heart and brain—organs that rely on a substantial, continuous supply of oxygen—are markedly affected by cyanide poisoning. Accordingly, most signs and symptoms of acute cyanide poisoning reflect the nonspecific effects of oxygen deprivation on the heart and brain. Exposure to smaller concen-

trations can initially cause respira- Mayes Photo Jeffrey tory activation (manifested by Firefighters and victims with smoke inhalation-associated cyanide hyperpnea and tachycardia) in an poisoning often experience cognitive dysfunction and drowsiness attempt to compensate for lack of that can impair the fight-or-flight response. oxygen followed by respiratory and myocardial depression. Early neurologic manifestations, PREHOSPITAL Care reflecting initial effects of brain oxy- Aggressive airway management with delivery of gen deprivation, include headache, 100% oxygen can save lives: giddiness and anxiety. Later mani- • Intubate if the patient is unconscious or the airway cannot festations of exposure to smaller be protected. concentrations or early manifestations of exposure to large concentra- • Establish an IV line, and provide cardiac monitoring. tions include cardiac arrhythmias, • Administer sodium bicarbonate if the patient is unconscious stupor, coma and seizure that culmi- or hemodynamically unstable. nate in respiratory depression and • Administer cyanide antidotes in prehospital care if diagnosis death.4,14,19 is relatively certain. Avoid the sodium nitrite portion of the Successful intervention for Taylor cyanide antidote kit (also called the Lilly or Pasadena cyanide poisoning depends primari- kit) in patients with smoke inhalation. Such treatment gener- ly on the concentration of exposure ally should involve online medical control. Anticonvulsants and the time between exposure may be needed for generalized seizures. Vasopressors (e.g., and treatment. Clearly, it is critical epinephrine) are indicated for hypotension not responsive that treatment is administered as to a fluid challenge. quickly as possible after exposure. • Although poor tissue utilization of oxygen in cyanide poison- Therefore, presumptive diagnosis of ing should theoretically render supplemental oxygen admin- cyanide poisoning and empiric istration useless, supportive care with administration of treatment prove necessary. oxygen alone has proven effective in a number of poisonings. PREHOSPITAL INTERVENTION Emergency Department Care: Initial ED care is Prehospital management of acute identical to that provided in prehospital phase: cyanide poisoning in the smoke- • Consider antidotal therapy if diagnosis is strongly suspected. inhalation victim involves moving the victim from the source of expo- • Begin antidotal therapy without waiting for laboratory sure (while maintaining appropriate confirmation. provider respiratory protection, • Avoid sodium nitrite portion of the Taylor cyanide SCBA), restoring or maintaining air- antidote kit in patients with smoke inhalation unless way patency, administering 100% carboxyhemoglobin concentration is very low (<10%).1 oxygen via non-rebreather mask or bag-valve mask technique, aggres-

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 13 inhalation victims with cyanide poisoning, concurrent carbon monoxide poisoning almost always compro- mises the blood’s oxygen-carrying capacity. Superimposing additional reductions in oxygen-carrying capacity of the blood from antidote- induced methemoglobinemia is potentially dangerous and even fatal. The currently available cyanide antidote may also cause severe hypotension, an effect that counteracts efforts to achieve hemodynamic stability in fire victims.3,16,17 Hydroxocobalamin, a precursor of vitamin B12, is being investigated for possible introduction in the United Photo Glen E. Ellman States to meet the need for an anti- Prehospital management of acute hydrogen cyanide poisoning dote that can be used safely on an includes moving the victim away from the source of exposure, empiric basis. Hydroxocobalamin restoring or maintaining airway patency, administering 100% has been available for nearly a oxygen via a non-rebreather mask or bag-valve technique, decade in France, under the name providing aggressive advanced airway management and cardiopulmonary support, and stabilizing vital signs. Cyanokit™ (Merck-Santé s.a.s) and is the antidote used by the Paris sive advanced airway management, Fire Brigade.1 Hydroxocobalamin including early intubation, providing detoxifies cyanide by binding with cardiopulmonary support and stabi- it to form cyanocobalamin (vitamin lizing vital signs, including the use of B12), which in excess is excreted in trauma and burn management the urine.17,18 Should it become (Parkland formula). When clinically available in the United States, indicated, anticonvulsants (benzodi- hydroxocobalamin potentially will azpines) should be given for enable prehospital antidotal treat- seizures, epinephrine and antiar- ment of cyanide poisoning in smoke- rhythmics to stabilize cardiovascular inhalation victims. The ability to function, and sodium bicarbonate administer an antidote in the prehos- to correct metabolic acidosis if pital setting should increase the known.4,5,13,15,19 speed of intervention and, arguably, Effective cyanide antidotes exist. its effectiveness. However, a cyanide antidote appro- For now,the best course of prehos- priate for use in smoke-inhalation pital intervention is the provision of victims is not yet available in the rapid transport to a hospital ED or United States, where the cyanide burn center where definitive treat- antidote kit (also called the Lilly kit, ment can be delivered. Successful Taylor kit or Pasadena kit) is the only antidote currently available. FINAL WORD intervention for The kit consists of amyl nitrite, thio- Research suggests that cyanide cyanide poisoning sulfate and sodium nitrite.15 should be expected in fire victims’ The cyanide antidote kit should blood and is often as great a threat as depends not be used outside of a hospital in carbon monoxide. Morbidity and primarily on the smoke-inhalation victims. The mortality from smoke inhalation- nitrites in the kit reduce the blood’s associated cyanide poisoning are concentration of oxygen-carrying capacity by bind- preventable if cyanide poisoning is exposure & the ing with hemoglobin to form suspected or promptly recognized methemoglobin, which binds and and antidotal therapy initiated time between neutralizes cyanide. Problematically, shortly after cyanide exposure. exposure & inducing methemoglobinemia can Hydroxocobalamin, currently under also significantly reduce the blood’s FDA evaluation, may offer a favor- treatment. oxygen-carrying capacity. In smoke- able risk-benefit ratio that allows for

14 JEMS COMMUNICATIONS its empirical use in the prehospital Physician. 48:107–114, 1993. setting. 5. Lee-Chiong TL: “Smoke inhalation injury.” Postgraduate Medical Journal. Richard Louis Alcorta, MD, FACEP, 105:55–62, 1999. is the state EMS director for the Maryland 6. Baud FJ, Barriot P,Toffis V,et al: “Elevated blood cyanide concentrations Institute for Emergency Medical Services in victims of smoke inhalation.” New Systems (MIEMSS). He is also the England Journal of Medicine. Maryland medical director of the Chemical 325:1761–1766, 1991. Stockpile Emergency Preparedness 7. Silverman SH, Purdue GF,Hunt JL, et Program and an emergency al: “Cyanide toxicity in burned patients.” specialist/physician. A former paramedic Journal of Trauma. 28(2):171–176, 1988. liaison at the Suburban Hospital in 8. Birky MM, Clarke FB: “Inhalation of Bethesda, Md., Alcorta is a fellow of the toxic products from fires.” Bulletin of the American College of Emergency New York Academy of Medicine. 57(10):997–1013, 1981. Physicians and is board-certified in emer- 9. Teige B, Lundevall J, Fleiscer E: gency medicine by the American Board of “Carboxyhemoglobin concentrations in Emergency Medicine. He is also a certified fire victims and in cases of fatal carbon Maryland state EMT-paramedic instructor, monoxide poisoning.” Zeitschrift fur hospital hazardous material instructor and Rechtsmedizin (Journal of Legal Advanced Trauma Life Support instructor. Medicine). 80(1):17–21, 1977. Alcorta is a member of many professional 10. Norris JC, Moore SJ, Hume AS: organizations, including the Alpha Omega “Synergistic lethality induced by the combination of carbon monoxide and Alpha Medical Honor Society, the cyanide.” Toxicology. 40:121–129, 1986. American Medical Association, the 11. Alarie Y:“Toxicity of fire smoke.” American College of Emergency Critical Reviews in Toxicology. Physicians, the National Association of 32:259–289, 2002. EMS Physicians and the National 12. Purser DA, Grimshaw P,Berrill KR: Association of State “Intoxication by cyanide in fires: a EMS Directors. study in monkeys using polyacryloni- trile” Archives of Environmental Health. Special thanks to Jane Saiers, PhD, who 39:394–400, 1984. completed the background literature 13. Koschel MJ: “Where there’s smoke, research on cyanide presented in this article there may be cyanide.” American Journal of Nursing. 102:39–42, 2002. This continuing education activity is 14. Chemical Casualty Care Division, approved by the Center for Emergency Aberdeen Proving Ground, Md. United Medicine, an organization accredited by the States Army Medical Research Institute Continuing Education Board for Emergency of Chemical Defense: Medical Medical Services (CEBEMS), for 1.5 hours Management of Chemical Casualties credit for First Responder, Basic and Handbook, 3rd ed. The Virtual Naval Advanced providers. Hospital Project, 1997–2004. 15. Sauer SW,Keim ME: “Hydroxocobalamin: improved public REFERENCES health readiness for cyanide disas- 1. Borron SW,Gaud FJ: “Toxicity, cyanide.” ters.” Annals of Emergency Medicine. February 2003. 37: 635–641, 2001. www.emedicine.com/emerg/topic118.ht 16. Hall AH, Rumack BH: “Clinical toxicol- m. Accessed Jan. 13, 2004. ogy of cyanide.” Annals of Emergency 2. Smoke Component Yields from Room- Medicine. 15:1067–1074, 1986. scale Fire Tests, Fire Research Division, 17. Hall AH, Kulig KW,Rumack BH: Building and Fire Research Laboratory, “Suspected cyanide poisoning in National Institute of Standards and smoke inhalation: complications of Technology, Gaithersburg, Md., 20899- sodium nitrite therapy.” Journal de 8664, 2002. Toxicologie Clinique et Expérimentale. 3. Kulig K: “Cyanide antidotes and fire 9:3–9, 1989. toxicology.” New England Journal of 18. Mégarbane B, Delahaye A, Goldgran- Medicine. 325:1801–1802, 1991. Toledano D, Baud FJ: “Antidotal treat- 4. Agency for Toxic Substances and ment of cyanide poisoning.” Journal of Disease Registry. U.S. Department of the Chinese Medical Association. Health and Human Services, Public 66:193–203, 2003. Health Service. American Family (continued on next page)

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 15 SMOKE INHALATION & ACUTE CYANIDE POISONING CE TEST #199

1. EMS providers are most likely to 8. HbCO is a measure of: 15. Which of the following is true of encounter acute cyanide poisoning a. the interaction between cyanide and cyanide antidotes? in patients: carbon monoxide a. Currently, no effective antidote exists a. who intentionally overdose on cyanide in b. cyanide levels in the blood b. Effective antidotes for smoke-inhalation a suicide attempt c. carbon monoxide poisoning patients are not available in the United b. accidentally poisoned through improper d. cyanide levels in inhaled air States food storage c.The current cyanide antidote kit used in c. poisoned through occupational exposures 9. A conclusion from the 2002 meta the United States is an effective and d. with smoke inhalation from a closed- analysis of fire deaths is that: safe treatment space fire a. patients rarely were exposed to both d.The antidote kit available in the United cyanide and carbon monoxide States may not be effective, but it will do 2. Synthetics used in manufacturing b. patients frequently had lethal cyanide no harm today: exposures a. are heavier than traditional building c. carbon monoxide was a better 16. Hours after exposure, the cyanide materials determinant of death than cyanide blood level of monkeys exposed to b. ignite slowly and burn with low intensity d. carbon monoxide levels were not a sub-lethal cyanide doses showed: c. burn cleanly with little toxic chemical determining factor in patient deaths a. no elevation emission b. moderate elevation d. burn hotter than traditional building 10. Sub-lethal concentrations of cyanide c. marked elevation materials can lead to: d. extremely high levels a. rapid incapacitation 3. Two of the most prevalent gases in b. minor changes in alertness 17. Cyanide causes toxicity by: smoke from most fires are: c. changes in mental status, but are rarely a. blocking the release of neurotransmitters a. hydrogen cyanide and carbon monoxide life-threatening b. deactivating the mechanism by which cells b. carbon dioxide and hydrogen sulfide d. few changes in patient condition unless use oxygen c. hydrogen sulfide and hydrogen chloride concentrations increase c. releasing histamine d. hydrogen chloride and carbon dioxide d. causing cells to rapidly use all 11. Cyanide poisoning is especially likely available oxygen 4. Hydrogen cyanide is likely to be in those patients who: produced: a. were in open-air fires 18. Patients with cyanide poisoning a. in low temperature fire conditions b. have hypertension following exposure to should be: b. in fires with high oxygen content smoke a. intubated only if they are in cardiac arrest c. by burning synthetic materials, never c. have a normal level of consciousness b. intubated if they cannot maintain their natural materials following an enclosed space fire own airway d. by the combustion of nitrogen- d. have soot in their nose or mouth c. managed without intubation due to poten- containing products tial damage to the trachea 12. Which of the following is typical of d. managed with low-flow oxygen to slowly 5. Which of the following is true of low concentration cyanide poisoning: restore oxygen levels hydrogen cyanide? a. stupor a. Hydrogen cyanide has a distinctive smell b. headache 19. Known metabolic acidosis due to b. Hydrogen cyanide is colorless c. tremors cyanide poisoning should be c. Hydrogen cyanide impairs muscular d. respiratory depression treated with: ability but not cognitive function a. vasopressors d. Hydrogen cyanide plays no role in early 13. Organs most commonly affected by b. anticonvulsants fire-related deaths cyanide poisoning include the: c. epinephrine a. lungs and heart d. sodium bicarbonate 6. One of the findings from the Paris b. liver and kidneys cyanide study was that: c. heart and brain 20. Which medication from the cyanide a. Cyanide may play a more important role d. stomach and intestines poisoning antidote kit should not than CO as a cause of death be administered in the prehospital b. Cyanide levels at the scene were not close- 14. Cyanide antidote kits available in the setting? ly related to cyanide levels measured later United States: a. amyl nitrite c. Cyanide played no role in determining the a. should be administered as soon as b. thiosulfate probability of death possible to all smoke inhalation victims c. sodium nitrite d. Carbon monoxide and cyanide appear to b. should be administered if CO poisoning d. atropine function independently of one another is suspected in addition to cyanide poisoning 7. Cyanide in the body: c. should be administered if the oxygen a. is not metabolized—it must be removed saturations in the blood are low The JEMS CE program is coordinated by the Center for Emergency with blood filtration d. should not be administered outside of the Medicine and the University of Pittsburgh, School of Health and b. is metabolized less efficiently by patients hospital Rehabilitation Sciences, which is accredited by the Continuing Education Coordinating Board for EMS to approve CE activities. with liver disease c. remains active until an antidote is delivered d. only presents a problem if CO is present

16 JEMS COMMUNICATIONS CE Answer Sheet #199 Smoke Inhalation & Acute Cyanide Poisoning Continuing Education That’s To be considered for credit, this test must be postmarked by August 15, 2005. Convenient &Affordable Name ______CE CREDITS: EASY TO EARN—EASY TO AFFORD Address______City/State/ZIP ______Earn CE credits in the comfort of your own home. MyWebCE makes it Organization______easy and affordable. Simply read the CE article, answer the accompanying State Certification # ______questions and send in the answer sheet. The test is worth 1.5 hours of Phone # ______credit approved by the Continuing Education Coordinating Board for E-mail ______EMS.Take one test at a time for $10 each, or save and earn faster CE by visiting myWebCE.com. S.S. # ______National Registry #______Send the completed test with your payment of $10, or one CE coupon, to: Skill Level: I EMT I EMT-I I Paramedic Area of Service: I Rural I Urban Jems Communications, Status: I Volunteer I Paid 525 B St., Suite 1900, San Diego, CA 92101-4495 ATTN: myWebCE Do you presently have a personal subscription to JEMS? I Yes I No Are you using this test as part of your requirements for recertification? I Yes I No

Name Instructions for Obtaining CE Credit 1. Study the CE article in this supplement. Title 2. Answer the test questions on this form that are appropriate to your level of care. (Photocopies of the answer strip are accepted if others wish to take the Address test; for grading purposes; however, the strip should not be enlarged or reduced.) 3. Mail completed answer strip with $10 testing fee City State ZIP or program coupon to: JEMS COMMUNICATIONS Phone ( ) 525 B ST., STE. 1900 SAN DIEGO, CA 92101-4495 ATTN: MYWEBCE Total payment ❏ Visa ❏ MasterCard ❏ Discover $ 800/266-5367 TOLL-FREE PHONE 4. Within six weeks, you will receive your test score and, Acct. # Exp. Date if you passed, a CE certificate.The passing score is 70%. 5. Please retain all course materials for future reference. Signature Answers Mark your answers in the appropriate box (1–20) (I) ❏ My check is enclosed, payable to Jems Communications Paramedics graded on 1–20 (required), 6 errors = fail. EMTs and others are graded on questions 1–15 (16–20 corrected FYI), 4 errors = fail.

1. I a. I b. I c. I d. 11. I a. I b. I c. I d. 2. I a. I b. I c. I d. 12. I a. I b. I c. I d. 3. I a. I b. I c. I d. 13. I a. I b. I c. I d. 4. I a. I b. I c. I d. 14. I a. I b. I c. I d. For faster CEU, visit www.myWebCE.com. 5. I a. I b. I c. I d. 15. I a. I b. I c. I d. With real-time testing & grading, 6. I a. I b. I c. I d. 16. I a. I b. I c. I d. your certificate is only a click away! 7. I a. I b. I c. I d. 17. I a. I b. I c. I d. 8. I a. I b. I c. I d. 18. I a. I b. I c. I d. MyWebCE.com is separate from, but related to, the print CE program.This course will be adapted for the Web and posted within 30 days. However, you 9. I a. I b. I c. I d. 19. I a. I b. I c. I d. cannot take this print CE test online or submit it via the myWebCE site. 10. I a. I b. I c. I d. 20. I a. I b. I c. I d.

EMD 08/04

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 17 HYDROXOCOBALAMIN:HYDROXOCOBALAMIN: TreatmentTreatment forfor SmokeSmoke Inhalation-AssociatedInhalation-Associated CyanideCyanide PoisoningPoisoning

Meeting the Needs of Fire Victims BY J. L. FORTIN, MD, M. RUTTIMAN, MD, L. DOMANSKI, MD, & J. J. KOWALSKI, MD The United States lacks a cyanide antidote useful for smoke- inhalation victims when cyanide toxicity is suspected on the basis of physical symptoms but is unconfirmed by laboratory assay—arguably the most common occurrence of acute cyanide poisoning. However, hydroxocobalamin, a cyanide antidote with a favorable history of usage by the Paris (France) Fire Brigade, may offer a treatment option superior to that which is currently available in the United States. The cyanide antidote kit made by Taylor Pharmaceuticals (also known as the Pasadena kit or the Lilly kit for the company that originally made it) is the only currently available cyanide antidote in the United States.

THE PROBLEM IS THAT When added to the blood oxygen- the Taylor kit has its limitations. depriving effects of carbon monox- The Taylor kit, a multicomponent ide poisoning, antidote-induced kit consisting of inhaled amyl reductions in the oxygen-carrying nitrite, IV sodium nitrite and IV capacity of smoke-inhalation vic- sodium thiosulfate, may be associ- tims’ blood can be dangerous and ated with such effects as severe possibly fatal. hypotension, vomiting and methe- Because of this potential toxicity, moglobinemia formation, which the Taylor kit is rarely used to treat results in a reduction of the blood’s smoke-inhalation victims and is oxygen-carrying capacity.The latter administered only when cyanide effect, in particular, precludes the poisoning is confirmed by a labora- use of the Taylor kit in most smoke- tory or very strongly suspected via inhalation victims. In addition to direct evidence of cyanide exposure being a source of cyanide poison- or ingestion. Further, its use is often ing, smoke inhalation is almost restricted to hospital settings always associated with concomitant because of the demands of manag- carbon monoxide poisoning, a state ing potentially dangerous antidote- characterized by deficient blood associated side effects. The cyanide oxygenation. Like carbon monox- antidotes dicobalt-EDTA and 4- ide, the amyl nitrite and sodium dimethylaminophenyl are available nitrite found in the Taylor kit are in Europe; however, they, like the methemoglobin formers, which Taylor kit, are associated with some reduce oxygenation of the blood. significant safety concerns.

18 JEMS COMMUNICATIONS HYDROXOCOBALAMIN The cyanide antidote hydroxocobal- SYNERGISTIC EFFECTS amin (Cyanokit™, Merck-Santé Carbon Monoxide Hydrogen Cyanide s.a.s.) is being studied for possible introduction in the United States to • Neurological alteration • Neurological alteration • Normal respiration • Respiratory frequency address the unmet need for a safe disturbance or apnea and effective antidote that may be used empirically for victims of smoke inhalation as well as for other source or route. Other published sources of cyanide poisoning. therapeutic uses of hydroxocobal- Hydroxocobalamin, a precursor of amin include its use in treatment of vitamin B12 (see figure p. 20), neu- pernicious anemia, hepatic insuffi- tralizes cyanide by fixing it to form ciency, encephalopathy, neuropathy, cyanocobalamin (vitamin B12), a amblyopia and various neuropsychi- nontoxic compound that is eliminat- atric syndromes. The Taylor kit ed in the urine. Hydroxocobalamin is commer- Hydroxocobalamin has been cially available in Europe as may be associated approved for use in France since Cyanokit™. According to its label- with such effects as mid 1996 and appears to be very ing, each kit includes two vials of 2.5 well tolerated, even at the high g hydroxocobalamin lyophilizate for severe hypotension, doses necessary to treat cyanide poi- reconstitution with 100 mL saline vomiting & soning. To date, it has no known per vial before use and two sterile major toxicities, and when adminis- transfer kits.The initial adult dose of methemoglobinemia tered acutely as a cyanide antidote, it hydroxocobalamin is typically 5 g formation, which has not been associated with any intravenously.Additional doses of up clinically relevant adverse events. to 15 g can be given according to the result in a However, it should be noted that the clinical status of the patient per the reduction of FDA has requested an additional labeling. The dosing instructions for safety study in human volunteers. hydroxocobalamin in the United the blood’s Because the molecule is red in States (should the antidote be oxygen-carrying color, hydroxocobalamin turns approved as anticipated) have yet to mucous membranes, skin and urine be established. capacity. red, and it may interfere with some specific colorimetric clinical labora- In addition to expected supportive care, victims of smoke- tory values, including aspartate inhalation from structural fires in the United States may benefit aminotransferase, total bilirubin, from prehospital treatment with hydroxocobalamin, which is creatinine and magnesium. No aller- routinely administered in the field to smoke-inhalation victims gic reactions have been documented of structural or enclosed-space fires in France. to the antidote administration; however, chronic use of small doses of hydroxocobalamin for vitamin B12 deficiency has been associated with rare allergic responses. Hydroxocobalamin has a history of clinical use for decades in countries other than the United States. Merck-Santé s.a.s. commercially registered hydroxocobalamin as an antidote for acute cyanide poisoning in France in 1996; however, it was prepared and used by multiple hospital pharmacies in France for several years prior to that time. It has also been used and studied as a cyanide antidote in other European countries, such as Spain, where it is considered to be an effective anti-

dote for cyanide toxicity from any Photo Glen E. Ellman

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 19 PARIS FIRE BRIGADE USE OF and possibly a state of shock. In addi- Conclusions Based HYDROXOCOBALAMIN tion, hydrogen cyanide poisoning is on Preliminary The Paris Fire Brigade comprises responsible for a deterioration of the DATA FROM 7,020 firefighters divided among 77 neurological state. An increase in lac- fire stations and responds to more tate, in particular, is related to hydro- PARIS FIRE than 18,000 fire-related incidents gen cyanide poisoning associated with BRIGADE annually. The department serves 759 carbon monoxide toxicity, because the square kilometers (roughly 450 body makes a compensatory switch to • Hydroxocobalamin appears square miles) with a population of anaerobic metabolism. to be a safe, effective more than 6 million.To meet the pop- cyanide antidote suitable ulation’s needs, the Paris Fire Brigade PARIS FIRE BRIGADE STUDY: for prehospital use for acute employs 50 doctors who specialize in PRELIMINARY DATA cyanide poisoning caused emergency medicine, 60 nurses and Hydroxocobalamin is routinely by smoke inhalation. 36 intensive-care ambulance drivers administered in the field to smoke- • An effective dose is 5 g (70 who operate seven intensive-care inhalation victims of structural or mg/kg) intravenously. ambulances. Each intensive-care enclosed-space fires in France. The mobile unit has one doctor, one nurse prehospital use of hydroxocobalamin and one driver on board. Hydroxo- by the Paris Fire Brigade over a five- cobalamin is part of the Paris Fire year period from January 1998 to Brigade’s standard treatment protocol December 2002 was evaluated in a for cyanide poisoning victims. retrospective study. Some data from Hydroxocobalamin, this study are available, and data col- CIRCUMSTANCES OF ACUTE lection and analysis are ongoing. a precursor of HYDROGEN CYANIDE POISONING According to a preliminary review vitamin B12, IN FIRES of the data, 70 of the 81 patients (41 Hydrogen cyanide is frequently asso- males and 40 females) treated with neutralizes ciated and acts synergistically with hydroxocobalamin (usually at a dose cyanide by carbon monoxide in cases of smoke of 5 g or 70 mg/kg) recovered cardiac toxicity in structural or enclosed- and/or respiratory function at the fire fixing it to form space fires where degrading synthetic scene, and 11 died. In a subset of 29 cyanocobalamin or natural substances release cyanide. patients in cardiac arrest before The synergistic adverse interaction of hydroxocobalamin administration, 18 (vitamin B12), a hydrogen cyanide with carbon patients spontaneously recovered nontoxic compound monoxide should not be underesti- cardiac activity following hydroxo- mated. This interaction can result in a cobalamin and adrenalin administra- that is eliminated reduction of respiratory frequency, tion (plus other supportive care) in an in the urine. even apnea, as well as hypotension average time of 19.3 minutes. Eleven patients receiving hydroxocobalamin FIGURE. Hydroxocobalamin is the and adrenalin died at the fire scene. precursor of vitamin B12. No side effects attributed to hydroxocobalamin were reported.This result- ed in a 62.1% survival rate following hydroxocobalamin administration in conjunction with the expected supportive care. Of the subset of 15 hemodynamically unstable patients, 12 had recovery of systolic blood pressure to >90 mmHg in 29 minutes, on average, after the end of hydroxocobalamin infusion. Rapid recovery of systolic blood pressure was observed even in severely hypoten- sive patients. These data suggest that hydroxocobalamin may improve hemodynamic stability in smoke-inhalation victims. This potential hemodynamic-stabilizing

20 JEMS COMMUNICATIONS property of hydroxocobalamin dif- Lead researcher Jean-Luc Fortin, In a subset of 29 ferentiates it from the cyanide anti- MD, is the chief of medicine, third divi- dote kit currently available in the sion, of the Paris Fire Brigade, one of the patients in cardiac United States, which can cause largest urban fire-and-rescue depart- arrest before severe hypotension. The hemody- ments in the world. Fortin is also an aux- namic-stabilizing property of iliary physician in the intensive-care burn hydroxocobalamin hydroxocobalamin may be particu- unit at the Army Teaching Hospital of administration, larly important in the prehospital Percy in Clamart, France. Before joining setting, where rapid attainment of the Brigade in 1999, Fortin was an emer- 18 patients hemodynamic stability is crucial for gency physician at the University Hospital spontaneously saving lives and enabling timely Center of Timone Emergency Medical Aid transport to the hospital. Service in Timone, France. He also served recovered as an emergency physician for the French cardiac activity CONCLUSIONS military as Director of Medical Care in the Accumulating data from an ongoing Navy Battalion Fire Brigade of Marseille following study on the prehospital use of (ambulance, emergency and intensive hydroxocobalamin hydroxocobalamin for cyanide poi- care service), and as an intensive-care soning suggest that it has a favorable physician at the Renee Le Bas Army & adrenalin risk-benefit ratio and a reasonable Hospital Center in Cherbourg, France. administration safety profile. Hydroxocobalamin at a Fortin received two inter-university diplo- dose of 5 g appears to be effective mas—one in subaquatic and hyperbaric (plus other and safe in smoke-inhalation vic- medicine in 1993 and another in higher supportive care) tims, as empiric treatment and as education in emergency medicine in 1999. prehospital treatment. With this pro- He received university diplomas in burn in an average time file, hydroxocobalamin may be capa- care and treatment, pediatric emergencies of 19.3 minutes. ble of fulfilling the currently unmet and radiological evaluation of medical/ need in the United States for a surgical emergencies. He is licensed in cyanide antidote that can be admin- emergency medical assistance, cata- istered safely in the prehospital set- strophic medicine, and aeronautical and ting as empiric therapy for smoke space medicine. inhalation as well as the range of Additional researchers: M. Ruttiman, MD, causes of cyanide poisoning. L. Domanski, MD, and J.J. Kowalski, MD.

Hydroxocobalamin has been approved for use in France since mid 1996 and appears to be very well tolerated, even at the high doses necessary to treat cyanide poisoning.

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 21 CYANIDECYANIDE ASAS AA CHEMICALCHEMICAL TERRORISMTERRORISM WEAPOWEAPONN

“Chance favors the prepared mind.”—Louis Pasteur BY MARC ECKSTEIN, MD, FACEP Several recent incidents in which cyanide was intended for use as a weapon of terror should cause emergency services personnel to pause and careful- ly consider the potential consequences. For example, many are unaware that cyanide was used during the 1993 World Trade Center bombing. In the aftermath, investigators found traces of cyanide in the vans in the parking garage that caused the explosion. Fortunately, the cyanide burned up in the explosion.1

OTHER RECENT INCIDENTS in cessful attack, particularly when we which cyanide was used but take into account the various received little press attention cyanide delivery methods available include the 1995 Tokyo subway to terrorists. attack, where the precursors of Cyanide differs from many other cyanide were found in the subway biological or chemical agents for bathrooms;1 the foiled 2002 al- which little or no defense is Qaeda attempt to use cyanide gas to available in that its individual and kill commuters in the London public-health effects are largely Underground;2 the 2002 arrests of remediable through appropriate four Moroccans (again with ties to preparedness and response. This al-Qaeda) who were plotting to use article discusses cyanide as a poten- cyanide to poison water supplies tial chemical terrorism weapon, around the U.S. embassy in Rome;3 cyanide sources, the attributes that the December 2002 recovery of a Fire smoke is an often-overlooked cyanide store in Paris linked to three source of cyanide exposure in suspected al-Qaeda operatives;4 terrorist bombings. Following the and, most recently, the May 2003 first World Trade Center bombing cyanide bomb found in the posses- in 1993, investigators found traces sion of white supremacists in Texas.5 of cyanide in the vans where the Although these events were thwart- explosion in the parking garage ed, it’s not difficult to envision a suc- originated.

22 JEMS COMMUNICATIONS AP/Wide Photos World

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 23 make it an attractive terrorism tool chemical weapons. Also, cyanide’s CYANIDE & and recent history of its use or primary site of action is not neces- INDUSTRY planned use as a terrorist weapon. sarily the bloodstream. In addition, strategies will be dis- Cyanide is commonly found in cussed for enhancing preparedness CYANIDE SOURCES industry settings, including: for a cyanide disaster. Current man- Cyanide exists in several forms, • Fumigating, electroplating agement of acute cyanide poisoning including the gases hydrogen cyanide and mining operations; and is considered in the context of and cyanogen chloride, soluble Centers for Disease Control and cyanide salts and insoluble cyanide Synthetic fiber, plastic, • Prevention (CDC) recommendations salts.13,14 Both gaseous and solid polymer, dye and for preparedness for chemical forms are used in industry. Cyanide pesticide production. attacks. is used in the recovery of gold and Cyanide is also a common by- U.S. governmental agencies, silver from mineral ores and of sil- product from the combustion of: including the CDC and the ver from photographic materials; in Department of Homeland Security, the production of plastics, pigments • Carbon- and nitrogen- consider cyanide among the most and dyes; and as a pesticide.13,1 containing synthetic likely agents of chemical terror- Moreover, hydrogen cyanide is substances; and ism.6,7 Other main categories of released as a combustion product • Natural substances, chemical weapons include nerve, during the combustion of plastics such as wood, silk and blister and pulmonary agents. One and other polymers, silks, wood, cot- cotton.1,13-14 of the most rapidly acting poisons, ton and many other nitrogen-con- cyanide shares several character- taining substances. istics of other chemical agents, Most literature on cyanide as a such as sarin and chlorine, that terrorist weapon focuses on the pos- render it a useful and effective tool sibility of the intentional release of for terrorists.8-12 hydrogen cyanide gas into enclosed spaces, such as office buildings or stadiums.10-12 Exposure to hydrogen Agents of cyanide via inhalation of fire smoke, CHEMICAL the most common source of cyanide poisoning in the United States, could TERRORISM also occur during a terrorist attack. Blood agents Blister agents Cyanide salts introduced into pharmaceuticals, the food supply and the • Hydrogen • Lewisite water supply also pose a terrorist cyanide • Nitrogen threat. • Cyanogen and sulfur Fire smoke is often overlooked as chloride mustards a source of cyanide exposure in a Nerve agents Pulmonary terrorist attack. Insofar as a terrorist • Tabun agents attack involves explosions and/or • Phosgene fire, cyanide is likely to be involved. • Sarin In fact, given the frequency with 6,10 • Soman • Chlorine which terrorist attacks involve fire, fire smoke is arguably the most likely source of cyanide in a terrorist Among many in the military, attack. Release of hydrogen cyanide cyanide continues to be known as a as a combustion product in closed- blood agent. This term, which is out- space fires should be considered Cyanide is easily dated and somewhat misleading, among the probable outcomes of obtainable by originated from the perception that any terrorist attack involving fire in cyanide is carried in the blood and an enclosed structure or vehicle. virtue of its that its primary site of action is the widespread use bloodstream. Although cyanide is THE IDEAL WEAPON carried in the blood, so too are other What makes cyanide an attractive in industry & chemical weapons, including terrorist weapon? To be most useful research absorbed nerve agents. Therefore, to a terrorist, a chemical agent the term does not differentiate should be plentiful and readily laboratories. cyanide from other categories of available and should not require

24 JEMS COMMUNICATIONS special knowledge to use. With these the potential use of cyanide to create Given the attributes, the terrorist does not panic, confusion and social disrup- need to spend significant time or tion during a cyanide-related terror- frequency with resources in procuring or preparing ism event. which terrorist to use the weapon and can procure Finally,cyanide poisoning requires the weapon while arousing minimal large quantities of specific resources attacks involve notice or suspicion. In addition, a to combat its effects. Moderate to fire, fire smoke chemical agent should be capable of high concentrations of cyanide can accomplishing terrorists’ primary be expected to cause death in the is arguably the goals of causing mass incapacitation majority of victims unless a cyanide most likely and casualties as well as causing antidote is quickly administered. mass confusion, panic and social Public health readiness for a large- source of disruption. Finally, the ideal terror scale cyanide disaster would entail cyanide in a weapon would require large quanti- stockpiling sufficient quantities of ties of specific resources to combat cyanide antidote. Correspondingly, terrorist attack. its effects—a feature associated with effective use of cyanide as a terrorist the reduced likelihood of adequate weapon is predicated on the lack of defense preparations.6,10 availability of large quantities of Cyanide possesses all of these antidote that can be rapidly dissemi- attributes. First, it is plentiful and nated and administered to affected readily available. Each year, the individuals. United States produces approximately three-quarters of a million HISTORICAL USES tons of cyanide. Cyanide is easily The recent history of cyanide’s actu- obtainable by virtue of its wide- al and intended use in intentional spread use in industry and research poisoning illustrates its utility as a laboratories. It is transported by weapon. Cyanide has been used as a truck and rail, both of which are sus- murder weapon, as a poison in indi- ceptible to theft, hijacking attempts vidual and mass suicides and and other terrorist acts that could attempted genocide, as a weapon of culminate in use of cyanide as a war and in recent attempted terror- weapon. ist incidents (described at the open- Second, cyanide does not ing of this article). The range of set- require special knowledge to use. tings in which cyanide has been Unlike some biological or chemical used and its various modes of deliv- weapons that require specific tech- ery illustrate its versatility as a nological or scientific proficiency weapon.The terrorist plots involving for effective use, cyanide incidents cyanide also suggest that it’s an can be planned and implemented important component of modern successfully by individuals without terrorists’ armamentarium.2-5,9,15-17 specific expertise or training. Cyanide was used as a murder Third, cyanide is capable of weapon several times in the past two causing mass incapacitation and decades in the United States. In the casualties. most notorious of these events, Fourth, cyanide is capable of causing mass confusion, panic and social disruption. Attributes of an Symptoms of cyanide poisoning IDEAL TERRORIST WEAPON are often dramatic and include stupor, seizures and coma. In a terrorist • Plentiful; • Capable of causing mass attack, these dramatic effects of • Readily available; confusion, panic and social disruption; cyanide poisoning may occur in the • Does not require a lot of absence of an immediately localiz- • Requires large quantities of special knowledge to use; able source of cyanide. The dramatic specific resources to combat presentation of cyanide poisoning, • Capable of causing mass its effects. its lethality and the difficulty in incapacitation and casualties; localizing its source during an emer- Cyanide possesses every one of these characteristics.6,10 gent terrorist incident contribute to

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 25 seven Chicagoans were killed in poisoning primarily reflect the SOURCES OF 1982 when they took cyanide-taint- effects of oxygen deprivation on the CYANIDE ed Extra Strength Tylenol® capsules. heart and brain and are dependent Other incidents of cyanide’s use as a on the route of exposure and severity EXPOSURE in a murder weapon involved beverages of exposure. The onset of signs and Terrorist Attack (Vanilla Coke®) and food (Lipton symptoms typically occurs seconds to Cup-A-Soup®). minutes after exposure, and death • Hydrogen cyanide gas Cyanide was also used to commit can occur within minutes after mod- released into an enclosed mass suicide in Jonestown, Guyana, erate to high levels of exposure.13,20 space (e.g., a stadium or where 913 followers of the Reverend an office building); Jim Jones died after drinking MANAGEMENT OF ACUTE • Fire smoke; cyanide-spiked Kool-Aid®. As an CYANIDE POISONING • Cyanide salts in the agent of genocide, cyanide (as Prehospital management of acute water supply; Zyklon B) was used to kill gas cham- cyanide poisoning involves moving • Cyanide salts in food; ber victims in concentration camps the victim from the source of expo- and/or during World War II. sure and providing supportive care, Cyanide has also been used as a including administering 100% oxy- • Cyanide salts in weapon of war, although its military gen, providing cardiopulmonary 10-12 pharmaceuticals. usefulness is limited by its high support and stabilizing vital signs. volatility, which results in rapid When clinically indicated, anticon- evaporation and dispersion, and its vulsants are given for seizures, epi- relatively high lethal dose compared nephrine and antiarrhythmics to with that of such agents as sarin. stabilize cardiovascular function, Cyanide was used as a war weapon and sodium bicarbonate to correct during WWI and, allegedly, WWII. metabolic acidosis. The Iraqis also allegedly used Supportive care is necessary but cyanide against the Kurds in the usually insufficient to save the lives 1980s.9 of cyanide poisoning victims; an Cyanide poisons cells by pre- antidote must also be given to venting them from using oxygen, counter the cellular effects of the an effect that causes them to rely toxin. Like supportive care, the anti- on anaerobic metabolism (i.e., oxy- dote must be administered within gen-independent metabolism, as minutes of exposure to moderate to opposed to the usual oxygen- high concentrations of cyanide in dependent metabolism), which order to be effective.1,21-22 causes accumulation of toxic byproducts. Accordingly, organs PREPARING FOR A most susceptible to cyanide toxicity CYANIDE ATTACK include the heart and brain, which By disabling the blood’s mechanism normally rely on a substantial and for carrying oxygen, cyanide can kill uninterrupted oxygen supply. quickly.At moderate to high concen- Clinical manifestations of cyanide trations of exposure, victims are

Recent Cyanide as an Cyanide as a Weapon of War History: Agent of Mass Suicide World War I: France used 1978: Jonestown, Guyana, 913 approximately 4,000 tons of Cyanide as a followers of the Reverend Jim cyanide. Murder Weapon Jones committed suicide with World War II: Japan allegedly 1982: Seven Chicagoans killed cyanide-spiked Kool-Aid®. used cyanide against China. 1986: One person killed World War II: United States Cyanide as an Agent of Genocide 1991: Two people killed maintained cyanide munitions. World War II: Cyanide 1992: One person killed 1980s Iraqi aggression: Iraq (as Zyklon B) was used in the allegedly used cyanide against 2003: One Maryland gas chambers in concentration the Kurds.9 teenager killed camps.

26 JEMS COMMUNICATIONS incapacitated within seconds to minutes, and death can occur within PLANNING PARAMETERS to Consider minutes. Unlike illness or toxicity There are several parameters emergency responders caused by many other biological and should consider when preparing for a cyanide attack: chemical weapons, cyanide poisoning can be effectively treated. • Cyanide kills quickly by disabling the blood’s mechanism for Because it progresses so quickly and carrying oxygen; because no diagnostic test can con- • It can incapacitate victims within seconds to minutes; firm cyanide poisoning in the time • It causes death within minutes following moderate to high required for initiating intervention, levels of exposure; cyanide poisoning must be diag- nosed presumptively by first • Unlike illness or toxicity caused by many other biological or responders on scene at a terrorist chemical agents, cyanide poisoning can be effectively treated; and attack. Rapid recognition and • Rapid recognition and empiric treatment by emergency empiric intervention by first respon- responders are necessary to reduce a chemical attack’s impact ders are crucial to saving lives and on individuals and the public health system.18,19 reducing morbidity.18-19 In 2000, a CDC taskforce collabo- rated with other groups to publish strategic recommendations for preparedness for and response to biological and chemical terrorism. The taskforce concluded that preparedness for terrorist attacks constitutes a critical component of the U.S. public health surveillance and response system, and they identified five activities that local, state and federal public health organizations should undertake in order to enhance preparedness for chemical attacks. For the United States to be prepared for a chemical attack involving cyanide, public health organizations need to develop action plans for and allocate resources to each of these preparedness activities.6 All of the activities outlined by the CDC taskforce apply to enhancing readiness for chemical terrorism involving cyanide. However, preparedness initiatives involving cyanide antidotes warrant particular attention because, at present, the availability of cyanide antidotes is wholly inadequate to meet the nation’s needs. The United States currently lacks an antidote with a risk-benefit ratio that favors empiric administration at the scene of a disaster.1

INADEQUACY OF CURRENT PREPAREDNESS

With appropriate preparedness, the AP/Wide Photos World public health threat posed by a Cyanide was used to commit mass suicide in Jonestown, Guyana, cyanide attack can be contained to where 913 followers of the Reverend Jim Jones died after drink- an extent. Containment is possible ing cyanide-spiked Kool-Aid®.

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 27 in part because signs and symptoms established. The sodium nitrite and CDC-Recommended of poisoning manifest instanta- thiosulfate are administered intra- PREPAREDNESS neously and dramatically after venously. Sodium nitrite and amyl exposure to moderate to high levels nitrite neutralize cyanide by binding MEASURES of cyanide, and they elicit the imme- with it to form methemoglobin. • Enhance epidemiologic diate attention of medical personnel Problematically, nitrite-induced capacity for detecting and and emergency responders trained methemoglobinemia reduces the responding to chemical to recognize chemical poisoning. blood’s ability to carry oxygen and attacks; The absence of significant delay thus constitutes a dangerous, poten- • Enhance awareness of between cyanide exposure and the tially fatal toxic state. In addition to chemical terrorism among onset of obvious, attention-com- causing methemoglobinemia, the EMS personnel, police manding signs and symptoms cyanide antidote kit may cause severe officers, firefighters, enhances the probability that hypotension leading to shock. These physicians and nurses; cyanide poisoning will be recog- liabilities contribute to a sub-optimal nized—a prerequisite for initiating risk-benefit ratio of the cyanide anti- • Stockpile chemical effective intervention. Unlike dote kit in empiric prehospital treat- antidotes; cyanide, many other poisons and ment of cyanide poisoning.1 • Develop and provide toxins are associated with a delayed Methemoglobinemia is especial- bioassays for detection and onset of illness and, correspondingly dangerous for smoke-inhalation diagnosis of chemical ly, a delay in diagnosis and interven- victims, who often have concurrent injuries; and tion. The fact that an effective carboxyhemoglobinemia due to • Prepare educational antidote exists differentiates carbon monoxide exposure. Both materials to inform the cyanide from many other chemical carboxyhemoglobinemia and methe- public during and after a and biological weapons that have no moglobinemia reduce the blood’s chemical attack.6 known effective countermeasure.1 oxygen-carrying capacity, and the additive effects of the two condi- THE CYANIDE ANTIDOTE KIT tions in smoke-inhalation victims Of several cyanide antidotes available can be lethal. Some authorities, around the world, only one, the therefore, do not recommend the cyanide antidote kit, is presently mar- cyanide antidote kit for smoke- keted in the United States. The inhalation victims, who often have cyanide antidote kit includes three concurrent cyanide and carbon- components that are to be adminis- monoxide poisoning, because of the tered sequentially: amyl nitrite, sodi- possibility of causing life-threaten- um nitrite and sodium thiosulfate. ing complications.23 The amyl nitrite (available as pearls) is administered via a mechanical ven- IMPROVING PREPAREDNESS: tilation device or by gauze sponge for HYDROXOCOBALAMIN inhalation to stabilize the victim dur- The cyanide antidote kit’s potential ing the time before an IV line can be toxicity and multiple-component

Cyanide Toxicity Acute Cyanide Poisoning Symptoms & Signs Small amounts of cyanide are Symptoms Signs metabolized in the liver and • Nearly immediate loss of • Respiratory arrest; excreted in the urine. consciousness; • Cardiac arrest; Cyanide binds to iron (Fe+++) • Stupor; in the mitochondria, prevent- • Coma; ing cells from using oxygen. • Giddiness; • Seizures; Without oxygen, cells die. The • Palpitations; • Pink or red skin color; effects are of progressive tis- • Dizziness; • Elevated venous blood sue hypoxia, and because the • Nausea/vomiting; oxygen concentration; and heart and brain are the • Hyperventilation; • Metabolic acidosis.13,20 organs most sensitive to hypoxia, they are the first • Drowsiness; and organs to be affected. • Eye irritation.

28 JEMS COMMUNICATIONS administration renders it ill-suited expert opinion, in order to effectively for use in terrorist incident response prepare for a cyanide disaster, the The United States and other situations requiring rapid United States should investigate, currently lacks prehospital intervention. The Food adopt, manufacture and stockpile and Drug Administration is current- hydroxocobalamin to prevent need- an antidote ly evaluating the cyanide antidote less morbidity and mortality.1 with a risk- hydroxocobalamin for possible In a June 2001 paper assessing introduction in the United States. A public health readiness for cyanide benefit ratio that precursor of vitamin B12, hydroxo- disasters, authors Samual Sauer, favors empiric cobalamin is currently available in MD, of the U.S. Army Medical Corp other countries, including France, and The School of Public Health at administration where it is the cyanide antidote used the University of Hawaii and Mark at the scene of by the Paris Fire Brigade. Keim, MD, of the CDC and the Hydroxocobalamin, which neu- Department of Emergency Medicine a disaster. tralizes cyanide by binding it to form at Emory University characterized vitamin B12, appears to be at least as the U.S. state of preparedness for a effective as the cyanide antidote kit cyanide disaster as abysmal. In the in the treatment of cyanide poison- context of terrorists’ continued ing but does not appear to be associ- interest in the use of cyanide as a ated with the safety liabilities weapon, the need to implement of the cyanide antidote kit. Hydroxocobalamin does not appear Firefighters emerge after cleaning toxic gas-contaminated cars at to induce methemoglobinemia or Tokyo's Kodemmacho subway station in March 1995. Although it cause hemodynamic instability. Its received little press attention, the precursors of cyanide were most common side effects are found in the subway bathrooms. thought to include discoloration of urine and mucous membranes and abnormalities in specific laboratory tests. These effects are transient (lasting one to two days) and do not appear to reflect clinically meaning- ful changes. From the literature, the safety risks of administering hydroxocobalamin appear to be negligible, and the antidote in France is administered at disaster scenes so that intervention is not delayed until hospital care can be provided. Further, because of its favorable risk-benefit ratio, as reported in the literature, hydroxocobalamin need not be reserved for cases of confirmed cyanide poisoning but can be administered in cases of suspected poisoning. Both of these attributes could lead to more rapid initiation of treatment than is possible with the currently available cyanide antidote kit and, thereby, could improve outcomes in a cyanide disaster.1,13-14,23-25 In other countries, hydroxocobalamin is recognized as an efficacious, safe and easily administered cyanide antidote with an extremely low adverse effect profile suitable for prehospital use in suspected

cyanide intoxication. According to AP/Wide Photos World

SMOKE INHALATION &HYDROGEN CYANIDE POISONING 29 rently stock one or fewer currently available cyanide antidote kits, and many emergency responders and other health-care providers are poorly informed in the use of the antidote and the recognition of cyanide poisoning. In conclusion, the recent history of use and planned use of cyanide suggests that a terrorist attack involving cyanide is quite possible in the United States. Cyanide poisoning can be treated effectively if it is treated quickly. The ability to manage a cyanide attack’s effect on individuals and public health depends on the speed of recognition and fast intervention. The potential introduction in the United States of hydroxocobalamin, an antidote with a promising risk-benefit ratio for empiric treatment, may help to enhance preparedness for a cyanide attack. However, progress is also necessary in other areas, including educating emergency responders and health-care professionals in the recognition and man-

Photo Glen E. Ellman agement of cyanide poisoning, and Any terrorist attack that involves explosions or fire in a structure raising public awareness of the or other enclosed space, such as a train, will likely involve the potential for a chemical weapons release of hydrogen cyanide. attack and how to respond.

the imperatives set forth by Sauer Marc Eckstein, MD, is the medical and Keim seems even more press- director of the Los Angeles Fire ing today than when their paper Department, an associate professor of originally appeared.1 emergency medicine at the Keck School of What would constitute adequate Medicine at the University of Southern preparedness for a chemical attack? California and the director of prehospital First, antidotes that are effective and care at Los Angeles County/University of The safety risks safe for empiric prehospital use Southern California Medical Center. A for- of administering should be made available in the mer New York City paramedic, Eckstein United States. Progress has been received his Doctor of Medicine from the hydroxocobalamin made on that front since the time of Mount Sinai School of Medicine in New are believed to be Sauer and Keim’s paper in that reg- York City. He holds numerous professional ulators are evaluating hydroxo- certifications, including an advanced oper- negligible, & the cobalamin for possible introduction ations certification on weapons of mass antidote is in the United States. destruction from FEMA, and serves as an To realize the potential benefits instructor in Chemical, Ordinance, administered of hydroxocobalamin, parallel Biological, Radiological Agent (COBRA) at disaster progress needs to occur in other incident response with the Office of aspects of readiness, including but Domestic Preparedness. He is a fellow of scenes so that not limited to developing plans for the American Board of Emergency intervention is ensuring local and regional avail- Physicians and a member of several pro- ability of antidote and educating fessional organizations, including the not delayed emergency responders and health- American College of Emergency until hospital care care professionals in the recogni- Physicians and the National Association of tion and management of cyanide EMS Physicians. can be provided. poisoning. Many U.S. hospitals cur-

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