Notes – Cyanide Exposure

Cyanide Exposure

Patient Safety Considerations

  1. In the event of multiple casualties, be sure to wear appropriate PPE during rescue evacuation from the toxic environment
  2. If the patient ingests cyanide, it will react with the acids in the stomach generating hydrogen cyanide gas. Be sure to maximize air circulation in closed spaces (ambulance) as the patient’s gastric contents may contain hydrogen cyanide gases when released with vomiting or belching
  3. Hydroxocobalamin is only agent safe for treatment of cyanide poisoning in pregnant patient

Notes/Educational Pearls

Key Considerations

  1. Pulse oximetry accurately reflects serum levels of oxygen but does not accurately reflect tissue oxygen levels therefore should not be relied upon in possible cyanide and/or carbon monoxide toxicity
  2. After hydroxocobalamin has been administered, pulse oximetry levels are no longer accurate
  3. If the patient ingests cyanide, it will react with the acids in the stomach generating hydrogen cyanide gas. Be sure to maximize air circulation in closed spaces (ambulance) as the patient’s gastric contents may contain hydrogen cyanide gases when released with vomiting or belching
  4. Amyl nitrite and sodium nitrite are no longer being used and no longer available in commercial kits

Pertinent Assessment Findings

  1. Early and repeated assessment is essential

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914043 – Exposure-Cyanide

Key Documentation Elements

  • Repeat evaluation and documentation of signs and symptoms as the patient’s clinical condition may deteriorate rapidly.
  • Identification of possible etiology of poisoning.
  • Time of symptom onset and time of initiation of exposure-specific treatments.
  • Therapy and response to therapy.

Performance Measure

  • Early airway management in the rapidly deteriorating patient
  • Accurate exposure history
    • Time of ingestion/exposure
    • Route of exposure
    • Quantity of medication or toxin taken (safely collect all possible medications or agents)
    • Alcohol or other intoxicant taken
  • Appropriate protocol selection and management
  • Multiple frequent documented reassessments

References

  1. Amyl Nitrite – Medical Countermeasures Database. Chemm.nlm.nih.gov. https://chemm.nlm.nih.gov/countermeasure_amyl-nitrite.htm. Updated January 2, 2013. Accessed August 28, 2017.
  2. Bebarta VS, Tanen DA, Lairet J, Dixon PS, Valtier S, Bush A. Hydroxocobalamin and sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of acute cyanide toxicity in a swine (Sus scrofa) model. Ann Emerg Med. 2010;55(4):345-51.
  3. Cyanide Poisoning. UpToDate.com. https://www.uptodate.com/contents/cyanide-poisoning?source=search_result&search=cyanide%20and%20pulse%20oximetry&selectedTitle=3~150. Updated September 28, 2016. Accessed August 28, 2017.
  4. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s Toxicologic Emergencies, 10th Edition. China: McGraw-Hill Education; 2015.
  5. Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm. 2012;69(3):199-212.
  6. Meridian Cyanokit (package insert). Semoy, France: Merck Santé; http://www.meridianmeds.com/sites/default/files/pi/CYANOKIT_PI.pdf. Accessed August 28, 2017.
  7. Roderique EJ, Gebre-Giorgis AA, Stewart DH, Feldman MJ, Pozez AL. Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. J Burn Care Res. 2012;Sep-Oct;33(5):624-33.
  8. Shepherd G, Velez LI. Role of hydroxocobalamin in acute cyanide poisoning. Ann Pharmacotherapy. 2008;42(5):661-9.
  9. Thompson JP, Marrs TC. Hydroxocobalamin in cyanide poisoning. Clin Toxicol (Phila). 2012;50(10):875-85.