Cyanogen Chloride Poisoning 

  • Author: Heather Murphy-Lavoie, MD, FAAEM; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Nov 17, 2011
 

Background

Cyanogen chloride (North Atlantic Treaty Organization [NATO] designation "CK") is 1 of 2 volatile cyanide military chemical warfare agents. The other similar agent is hydrogen cyanide, or AC. These agents first were used in large quantities by the French and British during World War I. Although the United States maintained 500-pound and 1000-pound cyanogen chloride (CK) bombs, these were not used during World War II. More recently, Iraq is suspected to have used a cyanidelike agent against the Kurds in the 1980s.

Cyanogen chloride vs hydrogen cyanide

Although cyanogen chloride (CK) and hydrogen cyanide (AC) are similar in their toxicity, a few important differences exist. Firstly, cyanogen chloride (CK) is less volatile than hydrogen cyanide (AC), making it more effective at low concentrations. Secondly, by nature of its chlorine moiety, cyanogen chloride (CK) causes irritation of the eyes and respiratory tract and potential delayed pulmonary toxicity similar to chlorine or phosgene gases. In high concentrations (eg, in enclosed spaces), this agent is rapidly acting and lethal, causing death within 6-8 minutes if inhaled at doses at or above its LCt50 (ie, lethal concentration that kills 50% of people) (11,000 mg·min/m3).

Cyanogen chloride and cyanide poisoning

Cyanogen chloride (CK) is synthesized in the United States for industry by Matheson Tri-Gas and is used as an organic precursor and in mining and metalworking. Therefore, an emergency physician may be more likely to encounter cyanogen chloride (CK)–exposed victims following an industrial accident rather than in a warfare or terrorism scenario.

The major source of cyanide poisoning in the United States does not come from cyanogen chloride (CK) but rather from smoke inhalation during house and/or industrial fires in which plastics (acrylonitriles, polyurethanes), wool, or silk are burned.[1, 2] Cyanide poisoning is also found in association with chemical synthesis, electroplating, mineral extraction, dyeing, photography, and agriculture.

See also Cyanide Toxicity, Hydrogen Cyanide Poisoning, as well as other topics in Warfare - Chemical, Biological, Radiological, Nuclear and Explosives.

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Etiology and Pathophysiology

Other than acts of terrorism or war, a mass casualty may develop in an industrial accident in which cyanogen chloride (CK) comes in contact with water (eg, during a fire-fighting expedition). Containers of cyanogen chloride (CK) may rupture or explode if exposed to high heat or following prolonged storage.

In addition to the local irritant effects of cyanogen chloride (CK), systemic toxicity occurs through mechanisms similar to those seen with hydrogen cyanide (AC) exposure.[3] Cyanogen chloride (CK) liberates a cyanide molecule, which enters the blood stream and distributes to tissues.[4] Once inside cells, cyanogen chloride (CK) binds to mitochondrial cytochrome aa3, interrupts electron transport, and creates imbalance between ATP synthesis and hydrolysis. Oxygen is unable to be used effectively as the terminal electron acceptor, which forces a shift to anaerobic metabolism. Although all organ systems are impacted, the most oxygen-dependent organs are the most affected (ie, brain, heart).

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Contributor Information and Disclosures
Author

Heather Murphy-Lavoie, MD, FAAEM  Assistant Professor, Assistant Residency Director, Emergency Medicine Residency, Associate Program Director, Hyperbaric Medicine Fellowship, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine

Heather Murphy-Lavoie, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jorge A Martinez, MD, JD  Clinical Professor, Department of Internal Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane School of Medicine

Jorge A Martinez, MD, JD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Cardiology, American College of Emergency Physicians, American College of Physicians, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Andre Pennardt, MD, FACEP, FAAEM, FAWM  Clinical Associate Professor of Emergency Medicine, Medical College of Georgia; Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Departments of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center

Andre Pennardt, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US, International Society for Mountain Medicine, National Association of EMS Physicians, Special Operations Medical Association, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Additional Contributors

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Suzanne White, MD Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

Disclosure: Nothing to disclose.

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