Cyanide Poisoning - Recognition and Treatment
/by Andrew Latimer, MD
Hey, everybody! Drs. Hinckley, Steuerwald, and myself sat down recently to talk a little bit about hydroxocobalamin (Cyanokit) and put together the attached podcast.
Here are a few take home points and additions regarding this cherry-colored elixir of wonder:
- Think about hydroxocobalamin in your hemodynamically unstable or otherwise SICK patients who have a history of smoke exposure in an enclosed space or a known industrial exposure to CN containing material. This stuff works fast and can be life saving.
- Hydroxocobalamin can turn your patient’s skin (and their body fluids, sclerae, nails, etc) all sorts of funky shades of red and orange. From pasty-guy-status- post-weekend-at-the-beach tinge to Hellboy shades of red. It can also cause a fairly impressive self-limiting acneiform rash. Let’s be honest, though, this is usually not the top of these patients' lists of worries.
- In the same vein as the above point, the administration of 5 grams of hydroxocobalamin can have a significant impact on many common laboratory tests that require colorimetric readings. It can make co-oximetry inaccurate and alter many clinical chemistry, hematology, coagulation and urine labs. If possible, consider drawing a rainbow of blood from the patient prior to administration of hydroxocobalamin (not likely if very unstable or in the prehospital setting) to better guide your resuscitation after medication administration.
- Hydroxocobalamin can cause transient hypertension during administration. Many patients are profoundly hypotensive when they are in a state that hydroxocobalamin is being considered, so this transient hypertension is typically not a major issue.
I hope you enjoyed the podcast! Remember that we now have hydroxocobalamin on all of the UC Health Air Care aircrafts, to be utilized in the community. Consider calling Air Care (513.584.CARE) if you feel that hydroxocobalamin may be necessary even if the patient ultimately will not need to be transported by helicopter, and even if you suspect the weather's not flyable (we'll work with you to find a way to get the drug to you by ground). We also have a stockpile of kits that can be delivered by Air Care aircraft (or by ground) in a mass exposure situation.
Prepublication Peer Review
There are thousands of plants that contain cyanogenic compounds; not just apricots, but this is not relevant. However, there is a cyanogenic naturopathic medication called Laetrile that has made the rounds as a purported cancer cure. I would stress two things: HCN is a “knockdown gas”; it can overcome a person within seconds. Anyone with an exposure-- either fire or industrial-- with coma, hypotension and acidosis should be considered a cyanide victim. Dr. Hinckley’s question about nonresponders: they may be overcome by other gases such as CO, HCL, H2S, etc. and that is likely why they are not responding.
-Dr. Mel Otten
Peer Review Provided by Dr. Mel Otten
