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termites), smoke inhalation from industrial fires Mechanism of toxicity: Cyanide affects virtually all body tissues, attaching itself to ubiquitous metalloenzymes and rendering them inactive Its principal toxicity probably results from inactivation of cytochrome oxidase (cytochrome a3) and, thus, cellular respiration, even in the presence of adequate oxygen stores Tissues with the highest oxygen requirements (eg, brain, heart, liver) are the most profoundly affected by acute cyanide poisoning Cyanide can induce fatality in seconds to minutes following inhalation or intravenous injection, in minutes following ingestion of soluble salts, or minutes (hydrogen cyanide) to several hours (cyanogens) after skin absorption Signs & Symptoms: (may not be noted by patients with genetic variability) bitter almond odor on breath bitter taste burning throat Lactic acidosis (due to blocked cellular oxygen consumption) Elevated measured venous oxygen saturation lock jaw hypotension seizures syncope & coma respiratory failure (agonal respirations) cardiovascular collapse Antidote / Treatment: ABC's including aggressive airway management with delivery of 100% oxygen Treat hypotension & seizures Amyl nitrite (inhaled) , sodium nitrite (i.v.) to induce the formation of methemoglobin (F3+) from hemoglobin, which will bind cyanide to form a non-toxic complex

And data collection may have been incomplete for behavioural questions in busy hospitals overwhelmed by COVID-19 cases

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[14] Among those who read the JAMA papers was San Francisco-based family law attorney Janet Mangini

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