Journal of Toxicology: Clinical Toxicology

ISSN: 0731-3810 (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ictx19

Suicide Attempt by Ingestion of Potassium

Ferricyanide

Philippe Hantson, Papa N'Geye, Marie Laforge, Jean-Luc Clemessy & Frédéric
Baud

To cite this article: Philippe Hantson, Papa N'Geye, Marie Laforge, Jean-Luc Clemessy & Frédéric
Baud (1996) Suicide Attempt by Ingestion of Potassium Ferricyanide, Journal of Toxicology: Clinical
Toxicology, 34:4, 471-473, DOI: 10.3109/15563659609013821

To link to this article: https://doi.org/10.3109/15563659609013821

Published online: 25 Sep 2008.

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 Clinical Toxicology, 34(4), 471-473 (1996)
LETTERS TO THE EDITOR
Suicide Attempt by Ingestion of
Potassium Ferricyanide
To the Editor:
Cyanide is included in various iron containing
metallic complexes. Some of them, like sodium
nitroprusside, administered intravenously, can
release cyanide, while other compounds like Prussian
Blue, given orally, are not cyanogenic.1*2We report
a case of suicide attempt due to the ingestion of
potassium ferricyanide, which is also known as
potassium hexacyanoferrate (K3Fe(CN)d or Prussian
Red (CAS 13746-66-2).
A 38-year-old nonsmoking woman ingested at
1730 one coffee spoon of a cyanide compound,
which could be later identified as potassium
ferricyanide and alcohol. She was found at 1800
conscious with blood pressure 150/80 mm Hg, heart
rate 110 bpm, and respiratory rate 16/min. As
cyanide poisoning was initially suspected, the
physician in the prehospital unit decided to optimize
tissue oxygenation by early intubation and mechan-
ical ventilation. Hydroxocobalamin (5 g) was also
infused as antidotal therapy. On arrival, 1 h after
the ingestion, consciousness was normal, and there
was no cyanosis. Blood pressure was 130/73 mm
Hg and heart rate 96/min. Chest and abdomen X
rays failed to reveal any abnormality. Arterial blood
gas analysis disclosed (FiO, 0.5): pH 7.44, PaC0,
4.74 KPa, PaO, 20.9 KPa, 0, saturation 99.3%,
total CO, content 25.1 mmol/L. Plasma lactate was
2.7 mmol/L (normal 1-2 mmol/L) and the anion gap
13 mmol/L. Blood ethanol was 34.1 mmol/L. The
clinical course was uneventful and the patient was
extubated 12 h after admission.
47 1
Serial samples were drawn for blood cyanide con-
centration and methemoglobinemia measurements3
(Figure 1). Cyanide determination in whole blood
was performed by spectr~photometry.~The blood
sample was placed in the outer ring of a Conway
dish and 2 mL of a buffered hydroxocobalamin
solution (0.052 M) was placed in the middle. After
the addition of 2 mL of sulfuric acid solution (11
M), cyanide concentration was determined by the
complexation of volatile hydrocyanic acid to
hydroxocobalamin and the absorbance at a
wavelength of 361 nm of the cyanocobalamin
formed. The initial cyanide concentration (20
mmol/L) was measured in a blood sample collected
before the administration of hydroxocobalaminto the
patient.
A manipulation was also carried out to assess the
in v h o release of cyanide. Increasing amounts of
K3Fe(CN), were placed in the outer ring of the
Conway dish and the same procedure was followed.
Table 1 shows that the release of cyanide was very
limited.
Potassium ferricyanide (Prussian Red) is mainly
used as a pigment for staining or in photography, but
also in analytical chemistry for its oxidizing
properties. Ferric ferrocyanide (Fe,[Fe(CN)&) or
Prussian Blue (CAS 14038-43-8) is administered to
treat radiocesium and thallium poisoning. Ferro- and
ferricyanides,as oxidizing agents, would be expected
to induce methemoglobinemia. Cyanide complex&
to metallic salts is generally considered weakly toxic
472 Letter to the Editor

-
- e--- - - 3 0.78
25 - 0.72
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\
20 \

10

t3.6

m
0.12
" 0.1
6:OO 6:30 a:30 9:30 11:30 1:30 2:oo
p.m. p.m. p.m. p.m. p.m. a.m. a.m.

Figure 1. Blood cyanide and methemoglobin concentrations.

Table 1
In Vitro Cyanide Release in the Presence of Increasing Amounts of K3Fe(CN)6

K3Fe(CN)( Theoretical CN CN Released (mg) ICN ReleasedCN

Amount (mg) Content (mg) in Conway Dish Theoretical

3 1.4 0
6 2.8 0.13 4.6
9 4.2 0.21 5
12 5.7 0.43 7.5
15 7.1 0.55 7.7

since the tight binding between the metal and the
cyanil group prevents cyanide release.5 No toxicity
has been reported after sustained treatment with
Prussian Blue in rats and short term therapy in
humans.2 Intestinal absorption of hexacyanoferrate
seems to be very small and only minute amounts
were shown to be absorbed in rats and piglets., No
reliable data concerning the bioavailability of
K,Fe(CN), seem to exist, while the bioavailability of
cyanide from hexacyanoferrate, which was more
recently investigated in humans, is very poor?
In our case, we were not able to measure directly
the amount of K,Fe(CN), in the blood. However,
mild methemoglobinemia was observed and subsided
spontaneously within eight hours after ingestion.
This suggests, from the oxidizing properties of
hexacyanoferrate, that only a small amount of
K,Fe(CN), was absorbed. The repeated measure-
ments of blood cyanide concentrations in this
nonsmoker patient showed the blood cyanide
Letter to the Editor
concentrations to remain well below the toxic levels
in humans. In our observation, repeated measure-
ments of arterial blood gases, anion gap and lactate
levels remained within normal range. These
biological data agree with a low systemic toxicity of
Prussian Red. Finally, all the colorimetric methods
for cyanide determination require the in virro
addition of a strong acid which could result in an in
virro release of cyanide from previously absorbed
Prussian Red.' We cannot assess whether the weak
blood cyanide concentrations we observed were
related to the in vivo or in vim0 release of cyanide
from Prussian Red.
In conclusion, this observation suggests that the
toxicity due to the ingestion of a single dose of
potassium ferricyanide in humans is minimal. As
very little cyanide seems to be released from the
complex, specific antidotal therapy to cyanide is
therefore not required.
Philippe Hantson, MD
Cliniques Universitaires St-Luc
Brussels, Belgium
Papa N'Geye, MD
Marie Laforge, MD
Jean-Luc Clemessy, MD
Fr&6ric Baud, PhD
Hopital Fernand Widal, Paris, France
473
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3. Evelyn KA, Malloy HT. Microdetermination of
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