Tox in The Land: Cyanide Toxicity - The Chicago Tylenol Murders of 1982

The Case

  • In 1982, a 12-year-old, Mary Kellerman passive after using an extra strength acetaminophen tablet

  • On that same day, Adam Janus also died after taking an acetaminophen tablet.

    • 2 family members also died within the upcoming days

  • 3 more Chicago residents died in a short period of time.

  • They were found to have all died from acetaminophen capsules laced with potassium cyanide

  • The bottles were able to be traced to different factories

  • The manufacturer, Johnson & Johnson shut down all production

  • Advisories were sent out to the public informing them to not take acetaminophen

  • It was determined that capsules were the only medication tampered with and those were replaced by J & J.

  • J & J was estimated to have lost approximately 100 million dollars.


How did this happen?

  • In 1982, medication packaging provided no sort of built-in security.

  • Think of shrink-wrap packing, peel-off lids on medications

  • Also, drinks with ‘freshness’ indicators/lids with breakable plastic seal

  • Ultimately because the bottles were from different factories it was determined that the tampering occurred in the stores and not in production

What did this lead to?

  • Copycat incidents

    • Further tampering with cyanide lead to several deaths throughout the 80s

  • Tamper-resistant packaging was developed

  • Product tampering made a federal crime

  • Pharmaceutical industry producing fewer capsules and more caplets

So how do you manage cyanide?

How are we exposed?

  • House fires

  • Chemical lab work

  • Hobbies

    • Electroplating, photography

    • Artificial nail remover

  • Nitroprusside infusions

  • Apricot and apple seeds



Mechanism of Toxicity & Clinical Effects

  • Inhibits oxidative metabolism by binding to cytochrome oxidase on its ferric ion

    • Lactic acidosis develops

  • Acute exposure

    • Rapid LOC, siezures, death

    • Hypotension, elecated lactate

  • Mild exposures

    • Nausea, vomiting, headache

    • SOB, HTN, tachycardia

    • AMS, seizures, coma

Workup & Management

  • Levels: 0.25mg/dL —> Lethal

  • Elevated lactate, acidosis

  • Management

    • Supportive

    • Remove from source

    • Optimize oxidation

    • Antidotes!

      • Lilly cyanide antidote kit

        • Sodium thiosulfate

          • Sulphur donor to aid in excretion

        • Amyl nitrite and sodium nitrite

          • Form methemoglobinemia to bind to the cyanide

      • Hydroxocobalamin

        • Vitamin B12 precursor

        • Acts as a chelator

POST BY: DR. RALEIGH EMS (R3)

FACULTY EDITING BY: DR. LAUREN PORTER (MEDICAL TOXICOLOGIST)

References

  1. https://www.crimemuseum.org/crime-library/cold-cases/chicago-tylenol-murders/

  2. Casefile: True Crime podcast Case 118

  3. https://interestingengineering.com/tamper-resistant-packaging-began-in-1982-with-7-still-unsolved-murders

  4. Fifis, Fran (February 5, 2009). "Law Enforcement To Review Tylenol Murders". CNN. Archived from the original on April 15, 2009. Retrieved March 7, 2010.

  5. "Tamper-Evident Packaging Requirements for Over-the-Counter Human Drug Products (Final Rule)". Federal Register. Food and Drug Administration, United States Department of Health and Human Services. 63 (213): 59463–59471. November 4, 1998. Archived from the original on February 1, 2017. Retrieved January 25, 2018.

  6. https://litfl.com/cyanide-toxicity

ToxLauren McCafferty