![]() Furthermore, these therapies are not developed for use by first responders or bystanders in the pre-hospital setting, creating a major treatment gap. Current FDA-approved therapies are not tailored specifically against oral cyanide poisoning. In contrast, inhalational exposures are dependent on the patient’s respirations and are limited secondary to the development of apnea from cyanide toxicity. With oral exposures, patients can have continued absorption of the toxin once it is ingested. In addition, oral exposures to cyanide may result in greater absorption when compared to the inhalational route. While the cellular mechanism of oral cyanide is not unique, the toxicokinetics and toxicodynamics of oral cyanide is, thus clinical effects are different than those of inhaled cyanide. They found 84.3% of the cases were from ingested cyanide, compared to 7.8% inhalation. Parker-Cote and colleagues conducted a systematic review of acute cyanide cases over a 48-year time period. Large-scale poisoning of the food supply could lead to mass casualties if we are not adequately prepared to respond to and do not have adequate supplies of the appropriate antidotes. In 2017, a terrorist plot to contaminate food supplies with cyanide was foiled and later in that same year, ISIS advised attackers to, “inject food for sale in markets with cyanide poison”. In 2015, the Office of the Director of National Intelligence released documents revealing that Osama Bin Laden planned to contaminate food supplies with cyanide. In 1982, seven people in the USA died after ingesting an over-the-counter medication laced with cyanide. One of the most well-known incidents of a large-scale oral cyanide poisoning was the Jonestown massacre, which resulted in more than 900 deaths after drinking cyanide-laced Flavor-Aid. Cyanide remains on the list of potential terrorist threats by various US governmental agencies. According to a study reporting data from the National Forensic Service headquarters in Seoul, Korea, there were 255 cyanide poisoning deaths reported from 2005 to 2010, the majority from self-harm. Oral cyanide in particular is the largest threat compared to other routes of exposure, with potassium cyanide (KCN) and sodium cyanide (NaCN) being the most frequently ingested cyanide salt. It is readily available, highly lethal, and easily weaponized. ![]() Current research is aimed at identifying an antidote that is safe, effective, easy to administer, and has a rapid onset of action.Ĭyanide poisoning, whether it be accidental or intentional, remains a major threat to civilians and military personnel worldwide. New therapies developed for oral cyanide exposures that are easily delivered, safe, and can be administered quickly by first responders in a mass casualty event are needed. Moreover, current therapies for cyanide poisoning are administered intravenously and are not specifically tested for oral exposures, which can result in higher cyanide doses and unique toxicodynamics. Current diagnostics of cyanide exposure can take hours or days, which can delay treatment. Articles referenced in this review were specific to risk, clinical presentation, diagnostics, current treatments, and developing therapies. A review of the literature using the PRISMA checklist detected 7284 articles, screened 1091, and included 59 articles or other reports. ![]() ![]() We will also review current strategies for developing new therapies. The aim of this review is to evaluate the risks of oral cyanide and its unique toxicokinetics, as well as address the lack of available rapid diagnostics and treatments for mass casualty events. There are no FDA-approved therapies tested for oral cyanide ingestions and no approved intramuscular or oral therapies, which would be valuable in mass casualty settings. The toxicokinetics and toxicodynamics of oral cyanide are unique, resulting in high-dose exposures, severe symptoms, and slower onset of symptoms. Terrorist organizations have threatened to attack the USA and international food and water supplies. Cyanide, a metabolic poison, is a rising chemial threat and ingestion is the most common route of exposure.
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