Cyanide 

Symptoms

• Anxiety
• Vertigo
• Weakness
• Headache
• Tachypnea
• Nausea/vomiting
• Dyspnea
• Tachycardia
• Severe poisoning causes altered mental status, arrhythmias, seizures, respiratory arrest

Clinical Management Options

EMT-B

• Place in position of comfort • 100% oxygen via non-rebreather mask or bag valve mask or advanced airway as indicated

Paramedic

• IV / IO access as appropriate for patient condition  • Consider obtaining EKG • Administer the Cyanokit • Adult: Initial dose is 5 g administered over 15 minutes slow IV • Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with 200 mL of LR, NS or D5W (25 mg/mL) and administered at 10-15 mL/minute • An additional 5 g dose may be administered with medical consultation. • Pediatric: Administer hydroxocobalamin (Cyanokit) 70 mg/kg (reconstitute concentration is 25 mg/mL) • Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with 200 mL of LR, NS or D5W (25 mg/mL) and administered at 10-15 mL/minute • 70 mg/kg = 2.8 mL/kg • Maximum single dose is 5 g

Pearls

• Cyanide should be suspected in occupational or other smoke exposures (e.g. firefighting), industrial accidents, natural catastrophes, suicide and murder attempts, chemical warfare and terrorism (whenever there are multiple casualties of an unclear etiology).
• Consider early in hypotensive, critically ill patients who are removed from a fire.
  • Many modern day materials produce cyanide when burned.