Suicide by Suicide by yyAcute Cyanide Ingestion Acute Cyanide Ingestion

in a 40 Year Old Malein a 40 Year Old MaleDouglas E. Rohde, MS Douglas E. Rohde, MS

Lake County Crime Laboratory, Painesville OHLake County Crime Laboratory, Painesville OH

William BlighWilliam Bligh--Glover, MD, Salvatore G. Rizzo, MDGlover, MD, Salvatore G. Rizzo, MDLake County Coroner’s Office, Painesville OHLake County Coroner’s Office, Painesville OH

David A. Engelhart, PhD, Amanda J. Jenkins, PhDDavid A. Engelhart, PhD, Amanda J. Jenkins, PhDCuyahoga County Coroner’s Office Cleveland OHCuyahoga County Coroner’s Office Cleveland OHCuyahoga County Coroner’s Office, Cleveland OHCuyahoga County Coroner’s Office, Cleveland OH

ObjectivesObjectivesObjectivesObjectives

Cyanide overviewCyanide overview

Occurrence and use of cyanideOccurrence and use of cyanide

Analysis of cyanideAnalysis of cyanide

As a means of suicideAs a means of suicide

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CyanideCyanide CNCNCyanide Cyanide –– CNCN

M.W. 26M.W. 26

HCN HCN –– gasgas

CHNOCHNO liquidliquid CHNO CHNO –– liquidliquid

NaCN KCNNaCN KCN –– solidsolid NaCN, KCN NaCN, KCN –– solidsolid

Almond odorAlmond odorDER DER -- LCCLLCCL

Naturally Occurring Naturally Occurring y gy gCyanideCyanide Vitamin B12 Vitamin B12

(cyanocobalamin)(cyanocobalamin)

Foods Foods –– cassava, cassava, peach, cherry, peach, cherry, p , y,p , y,corncorn

HCN releasedHCN released HCN released HCN released when wool, silk is when wool, silk is burnedburned

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Man Made CyanideMan Made CyanideMan Made Cyanide Man Made Cyanide

Vehicle exhaustVehicle exhaust

Tobacco smokingTobacco smoking

P d ti f l tiP d ti f l ti Production of plastics Production of plastics -- nitriles release HCN when burned nitriles release HCN when burned

Drug metabolism Drug metabolism -- Laetrile, Sodium NitroprussideLaetrile, Sodium Nitroprusside

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Laetrile, Sodium NitroprussideLaetrile, Sodium Nitroprusside

Industrial Cyanide UsageIndustrial Cyanide UsageIndustrial Cyanide UsageIndustrial Cyanide Usage

Fumigants and InsecticidesFumigants and Insecticides

F b i d i bl i tF b i d i bl i t Fabric dyeing, blueprintsFabric dyeing, blueprints–– prussian blue [ iron (III) ferrocyanide ]prussian blue [ iron (III) ferrocyanide ]

Metal tradesMetal trades–– mining, jewelrymining, jewelryg, j yg, j y

Cyanide salts Cyanide salts l t l til t l ti

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–– electroplatingelectroplating

Notable Cyanide EventsNotable Cyanide EventsNotable Cyanide EventsNotable Cyanide Events

LizzieLizzie BordenBorden

RasputinRasputin

WWII genocidal agentWWII genocidal agent –– Zyklon BZyklon B WWII genocidal agent WWII genocidal agent –– Zyklon BZyklon B

Jonestown massacreJonestown massacre

Tylenol poisoningTylenol poisoning

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Close-up of bag of Potassium Cyanide found in chemical / explosives weapons laboratory in

F ll j h (Offi i l USMC Ph t h)DER DER -- LCCLLCCL

Fallujah. (Official USMC Photograph)

Case HistoryCase HistoryCase HistoryCase History40 ear old Ca casian male40 ear old Ca casian male 40 year old Caucasian male40 year old Caucasian male

History of depression History of depression –– ongoing treatment via ongoing treatment via medication, counselingmedication, counseling

History of suicide in familyHistory of suicide in family History of suicide in familyHistory of suicide in family

Employed at electroplating facility Employed at electroplating facility -- KCN, KCN, NaCN AgCN ro tinel sed and accessibleNaCN AgCN ro tinel sed and accessibleNaCN, AgCN routinely used and accessibleNaCN, AgCN routinely used and accessible

Job duties Job duties -- bright dipping, nickel plating, bright dipping, nickel plating,

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chrome stripping of musical instrument partschrome stripping of musical instrument parts

Case HistoryCase HistoryCase HistoryCase History

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Case HistoryCase HistoryCase HistoryCase History

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Case HistoryCase HistoryCase HistoryCase HistoryD i i b k d d t f dD i i b k d d t f d During morning break, decedent found During morning break, decedent found unresponsive on floor by his deskunresponsive on floor by his desk

Blood on floor next to headBlood on floor next to head

Slight foaming of the mouthSlight foaming of the mouthg gg g

Eyes glossy, discoloration of faceEyes glossy, discoloration of face

MRT began CPR, no breathing, no pulseMRT began CPR, no breathing, no pulse

EMS assist, ET tube, epi, narcanEMS assist, ET tube, epi, narcanDER DER -- LCCLLCCL

EMS assist, ET tube, epi, narcanEMS assist, ET tube, epi, narcan

Case HistoryCase HistoryCase HistoryCase History

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Case HistoryCase HistoryCase HistoryCase History

Decedent took break in an area he had Decedent took break in an area he had never visited beforenever visited before

No evidence of food, drink, cigarettesNo evidence of food, drink, cigarettes

Handwritten note by lunch boxHandwritten note by lunch box

Plastic baggie with white powder located Plastic baggie with white powder located at work stationat work station

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Case HistoryCase HistoryCase HistoryCase History

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Autopsy FindingsAutopsy FindingsAutopsy FindingsAutopsy Findings

External exam: unremarkableExternal exam: unremarkable

ET tube 1ET tube 11/21/2” irregular laceration of left” irregular laceration of left ET tube, 1ET tube, 1 irregular laceration of left irregular laceration of left posterior parietal scalpposterior parietal scalp

Internal exam: severe pulmonary edemaInternal exam: severe pulmonary edema Internal exam: severe pulmonary edema, Internal exam: severe pulmonary edema, otherwise unremarkableotherwise unremarkable

Esophageal gastric mucosa normalEsophageal gastric mucosa normal Esophageal, gastric mucosa normalEsophageal, gastric mucosa normal

Microscopic exam: intraMicroscopic exam: intra--alveolar alveolar hemorrhage vascular congestionhemorrhage vascular congestion

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hemorrhage, vascular congestionhemorrhage, vascular congestion

Normal Mucosa Normal Mucosa --Esophagus and Gastric Esophagus and Gastric

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Toxicology SubmissionToxicology SubmissionToxicology SubmissionToxicology Submission

Femoral, cardiac bloodFemoral, cardiac blood VitreousVitreous UrineUrine GastricGastric

-- 120 ml brown fluid120 ml brown fluid SpleenSpleen SpleenSpleen LiverLiver LungLung

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LungLung

Toxicology AnalysisToxicology AnalysisToxicology AnalysisToxicology Analysis

Routine screens: Routine screens:

GCHS VolatilesGCHS Volatiles Meoh Etoh IsopropMeoh Etoh Isoprop GCHS Volatiles GCHS Volatiles –– Meoh, Etoh, Isoprop, Meoh, Etoh, Isoprop, Acetone, AcetaldehydeAcetone, Acetaldehyde

ELISA ELISA –– Amphet, Barb, Benzo, Thca, Amphet, Barb, Benzo, Thca, Cariso, Coc/be, Meth, Op, PCP, TCACariso, Coc/be, Meth, Op, PCP, TCA

GCMS Comprehensive Screen GCMS Comprehensive Screen -- A/N, A/N, BaseBase

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Cyanide Analysis Cyanide Analysis --y yy yQualitativeQualitative

Merckoquant Cyanide Test Merckoquant Cyanide Test (Merck, Germany)(Merck, Germany)

Detection of dissociable cyanide ions onlyDetection of dissociable cyanide ions only Detection of dissociable cyanide ions only, Detection of dissociable cyanide ions only, complexcomplex--bound cyanides not detectedbound cyanides not detected

Bl / l d l d dBl / l d l d d Blue / lavender color producedBlue / lavender color produced

Thiocyanate positive at >1 mg/LThiocyanate positive at >1 mg/LThiocyanate positive at 1 mg/LThiocyanate positive at 1 mg/L

Nitrate may cause increase in color response, Nitrate may cause increase in color response, permanganate chromate may cause decreasepermanganate chromate may cause decrease

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permanganate, chromate may cause decreasepermanganate, chromate may cause decrease

Cyanide Analysis Cyanide Analysis --y yy yQuantitativeQuantitative Separation of cyanide using Separation of cyanide using

Conway microdiffusion cellsConway microdiffusion cellsyy

Potentiometric measurement with Potentiometric measurement with electrode selective for cyanide ionselectrode selective for cyanide ions

Calibration curve of electrodeCalibration curve of electrode Calibration curve of electrode Calibration curve of electrode response vs. cyanide concentration response vs. cyanide concentration

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Cyanide Analysis Cyanide Analysis --y yy yQuantitativeQuantitative

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Cyanide Analysis Cyanide Analysis --y yy yQuantitativeQuantitative

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Cyanide ResultsCyanide ResultsCyanide ResultsCyanide Results

Cardiac Blood 261.3 mg/LCardiac Blood 261.3 mg/L Femoral blood 13.7 mg/LFemoral blood 13.7 mg/L Gastric contents 7024 mg/LGastric contents 7024 mg/L Urine 1.3 mg/LUrine 1.3 mg/Lgg Vitreous humor 4.5 mg/LVitreous humor 4.5 mg/L Lung 25 mg/kgLung 25 mg/kg Lung 25 mg/kgLung 25 mg/kg Liver 6.3 mg/kgLiver 6.3 mg/kg Spleen 314 mg/kgSpleen 314 mg/kg

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Spleen 314 mg/kgSpleen 314 mg/kg

Coroner’s RulingCoroner’s RulingCoroner’s RulingCoroner’s Ruling

Cause of Death: Cause of Death: Acute Cyanide IntoxicationAcute Cyanide Intoxication

Manner of Death:Manner of Death:Manner of Death: Manner of Death: SuicideSuicide

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DiscussionDiscussionDiscussionDiscussion

Cyanide affects virtually all tissues, Cyanide affects virtually all tissues, rendering metalloenzymes inactiverendering metalloenzymes inactive

Cyanide ion interrupts electron transport Cyanide ion interrupts electron transport chain in the inner membrane of chain in the inner membrane of mitochondrion mitochondrion –– stronger binding than Ostronger binding than O22 to to the Fethe Fe+3 +3 in cytochrome aain cytochrome aa33

Tissues with highest OTissues with highest O22 requirements are requirements are most affected by acute cyanide poisoningmost affected by acute cyanide poisoning

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DiscussionDiscussionDiscussionDiscussion

80% f id b li d hi80% f id b li d hi 80% of cyanide metabolized to thiocyanate 80% of cyanide metabolized to thiocyanate (SCN) via liver enzyme rhodanide synthetase(SCN) via liver enzyme rhodanide synthetase

Excreted through kidney and lungsExcreted through kidney and lungs

Normal cyanide concentrations:Normal cyanide concentrations:blood 0.016 mg/L (ns) 0.041 mg/L (s)blood 0.016 mg/L (ns) 0.041 mg/L (s)urine 0.067 mg/L (ns) 0.174 mg/L (s)urine 0.067 mg/L (ns) 0.174 mg/L (s)

Chronic workplace exposure:Chronic workplace exposure:blood 0.02blood 0.02--0.36 mg/L (ns) 0.36 mg/L (ns)

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blood 0.10blood 0.10--2.20 mg/L (s)2.20 mg/L (s)

DiscussionDiscussionDiscussionDiscussionFi Vi ti bl d 0 01Fi Vi ti bl d 0 01 4 36 /L4 36 /L Fire Victims: blood 0.01 Fire Victims: blood 0.01 -- 4.36 mg/L4.36 mg/L

32 fatal cases of cyanide ingestion revealed 32 fatal cases of cyanide ingestion revealed blood concentration 0 4blood concentration 0 4 230 mg/L230 mg/Lblood concentration 0.4 blood concentration 0.4 -- 230 mg/L230 mg/L

Ingestion:Ingestion:Bl d 12 4 Li 7 7 S l 43 9 U i 0 1Bl d 12 4 Li 7 7 S l 43 9 U i 0 1Blood 12.4 Liver 7.7 Spleen 43.9 Urine 0.1Blood 12.4 Liver 7.7 Spleen 43.9 Urine 0.1

Inhalation:Inhalation:Blood 7.0 Liver 0.8 Urine 2.0Blood 7.0 Liver 0.8 Urine 2.0

Case:Case:

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Blood 13.7 Liver 6.3 Spleen 314 Urine 1.3Blood 13.7 Liver 6.3 Spleen 314 Urine 1.3

DiscussionDiscussionDiscussionDiscussion

Cyanide may exhibit pm redistributionCyanide may exhibit pm redistribution

Heart / Femoral ratio 0 4Heart / Femoral ratio 0 4 2 4 (case H/F 19)2 4 (case H/F 19) Heart / Femoral ratio 0.4 Heart / Femoral ratio 0.4 –– 2.4 (case H/F 19)2.4 (case H/F 19)

Tissue distribution proportional to erythrocyte Tissue distribution proportional to erythrocyte content of organ (CB 261, FB 14, L 6, S 314)content of organ (CB 261, FB 14, L 6, S 314)

Minimum adult lethal dose 200 mg KCNMinimum adult lethal dose 200 mg KCN Minimum adult lethal dose 200 mg KCN Minimum adult lethal dose 200 mg KCN -- case 842 mg cyanide in gastric case 842 mg cyanide in gastric

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DiscussionDiscussionDiscussionDiscussion

Cyanide induces fatality in seconds to minutesCyanide induces fatality in seconds to minutes

8 fatal cyanide exposures reported to American8 fatal cyanide exposures reported to American 8 fatal cyanide exposures reported to American 8 fatal cyanide exposures reported to American Association of Poison Control Centers (1998)Association of Poison Control Centers (1998)

S i id b id d i t l iS i id b id d i t l i Suicide by cyanide occurs predominately in Suicide by cyanide occurs predominately in adult malesadult males

Occupational accessibilityOccupational accessibility-- chemists, electroplaters, jewelerschemists, electroplaters, jewelers

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Questions ?Questions ?Questions ?Questions ?

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