HWN Suggests

Hydroxycobalamin in Fire Related Cyanide Toxicity

Patients at risk for cyanide toxicity are those who present after being exposed to fire smoke in an enclosed area, may have soot present around the mouth, nose, and/or oropharynx, and have altered mental status. If a patient has suspected cyanide toxicity from smoke inhalation, they may benefit from hydroxycobalamin…

Hydroxycobalamin is dosed as 5 g over 15 minutes. A second dose may be administered up to a max of 10 g.

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 Cyanide Poisoning in Children

The Cyanide Antidote Kit is designed to be given in combination, but as was mentioned, the nitrites may be less desirable to use. Sodium Thiosulfate + Hydroxocobalamin: Sodium Thiosulfate can be given initially in the stable patient while awaiting lactate level. If lactate is elevated, then Hydroxocobalamin can be given.

 EM@3AM: Cyanide Toxicity

Serum cyanide levels are not readily available, therefore, cyanide toxicity needs to be diagnosed clinically as delays in treatment can result in significant comorbidities and death

 ToxCard: Cyanide Toxicity and Treatment

Empiric treatment with a cyanide antidote in a fire victim should be considered, especially when there was a history of loss of consciousness or the patient has significant acidosis.

Articles of Interest

Acute Cyanide Poisoning: Hydroxocobalamin and Sodium Thiosulfate Treatments with Two Outcomes following One Exposure Event

Presently, there are two widely accepted antidotes: sodium thiosulfate and hydroxocobalamin. These treatments act on different components of cyanide's metabolism. Here, we present two cases resulting from the same source of cyanide poisoning and the use of both antidotes separately used with differing outcomes.

Briefs: Cyanide poisoning

Pediatric patient – 70mg/kg IV (max 5g). Adults – 5g IV (kids ≥15 years). Give over 15 minutes, dose can be repeated if an incomplete clinical response is observed (second dose rate is administered over 15 minutes to 2 hours). Preparation of cyanokit is complex, and is included here for reference. Reconstitute each vial with 100 mL of 0.9% Sodium Chloride (may also use LR or D5W) using transfer spike, fill vial to line and leave vial in upright position, the resulting solution has a concentration of 25 mg/mL., rock or rotate the vial for 30 seconds to mix the solution, do not shake the vial, check for particulate matter, solution should be dark red.

Can Hydroxocobalamin be administered via intraosseous access for acute cyanide toxicity?

The finding of this study suggest that IO administration of Hydroxocobalamin is as efficacious as IV administration and its administration in acute cyanide toxicity should not be delayed due to lack of IV access when IO access is available.

Carbon Monoxide and Cyanide Poisoning

Cyanokit: Hydroxocobalamin. Cyanide preferentially binds hydroxocobalamin (forming cyanocobalamin), thereby freeing the cytochrome pathway. ;

Episode #1: EMCrit Episode #122 – Cyanide and Carbon Monoxide Toxicity

Hydroxocobalamin 5 g IV for adults or 70 mg/kg IV for pediatrics. Cyanide binds to hydroxocobalamin, forming cyanocobalamin (vitamin B12) which is renally excreted. It also turns everything red, which can interfere with labs and dialysis.

Episode 20- Cyanide: toxicology and antidotes

For antidotes, the first-line agent is Cyanokit (hydroxocobalamin) which binds CN to form cyanocobalamin (vitamin B12). The dose is 5g IV over 15 minutes in adults and 70 mg/kg (max of 5 g) over 30 minutes in peds, with a repeat dose in 1-2 hours if needed. Adverse effects include hypotension, allergic reactions, and red discoloration of skin, mucous membranes, and urine.

Smoke Inhalation and Adverse Health Consequences

Any patient who presents from an enclosed-space fire should be assessed for cyanide toxicity. There is no quick test (such devices are in development); however, some clinical symptoms and signs can allow an assumption of possible cyanide exposure

Smoke Inhalation and Cyanide Exposure

Crews will generally look to administer hydroxocobalamin and sodium thiosulfate through two separate lines, although if only one vascular access site is available, they are instructed to administer the hydroxocobalamin first, followed by a 20 mL flush, in order to prevent its inactivation by sodium thiosulfate.

Toxicology Notes: Considerations for Cyanide Treatment in the Emergency Department

Hydroxocobalamin is an effective and safe medication to administer in cyanide poisoning. It should not be delayed when there is clinical suspicion for exposure, however consider drawing additional laboratory studies that may be useful in the next several hours and warning your pediatric intensivist that future lab values and dialysis may be affected by this medication. And be on the look-out for new therapies that are right around the corn

Resources

Cyanokit

Hydroxocobalamin, the active ingredient in CYANOKIT, has been used in France since the 1980s, was formally licensed there in 1996, and was approved in the United States in 2006 to treat known or suspected cyanide poisoning6,

Life in the Fastlane

give antidote if suspected toxicity: hydroxocobalamin then sodium thiosulfate is generally preferred if available.

StatPearls

Hydroxycobalamin is the antidote of choice for acute cyanide poisoning, especially if the patient has coexisting carbon monoxide poisoning. Other antidotes, which will be discussed later, impair oxygen-carrying capacity and worsen cellular hypoxia and acidosis. The standard dose is 5 grams given intravenously (IV over 15 minutes, Be aware that this antidote turns urine dark red; this is not due to myoglobinuria. A cyanide antidote kit may be used in place of hydroxocobalamin if it is not available.