Hello and welcome to Episode 20 of ER-Rx. You can repeat ½ of the dose after 30 min if needed The dose is 12.5 g IV over 10 min in adults or 400 mg/kg (with a max of 12.5 g) in peds. However, it has a slow onset of action of up to 1 hour. – The other component of this kit was sodium thiosulfate, which works by donating the sulfur necessary for the rhodanese enzyme. The adverse effects of methemoglobinemia, hypotension, and bradycardia led to this kit becoming a less favorable option, especially in patients who also have possible carbon monoxide exposure Nitrites work by generating methemoglobin, as CN has a higher affinity for methemoglobin than for cytochrome oxidase. This kit continued amyl nitrite, sodium nitrite, and sodium thiosulfate.
– Historically, the Cyanide Antidote Kit was available, but it is no longer manufactured. Adverse effects include hypotension, allergic reactions, and red discoloration of skin, mucous membranes, and urine 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. – For antidotes, the first-line agent is Cyanokit (hydroxocobalamin) which binds CN to form cyanocobalamin (vitamin B12). Labs should include an ABG, BMP, lactate, whole blood CN level, CBC, blood gases, and carbon monoxide levels – Management consists of supportive care initially. – In smoke inhalation victims, the presence of soot in the mouth or nose, altered mental status, and an elevated lactate can be signs of CN exposure A lactate > 8 mmol/L has a PPV of 64% and a NPV of 98% for CN concentrations above 1 mcg/mL
– A good surrogate measure of CN concentrations is lactate. – CN levels are not readily available, but levels > 3 mcg/mL lead to death and lower levels can cause a spectrum of coma, reduced consciousness, and/ or tachycardia – Sign/symptoms include agitation, confusion, seizures, coma, and respiratory/ cardiovascular collapse – CN acts as a “chemical asphyxiant” by inhibiting cytochrome oxidase, which is essential for aerobic energy production. In acute poisoning the rate-limiting step of rhodanese is the availability of sulfur donors – CN is typically eliminated through the conversion to thiocyanate by the rhodanese enzyme.
– Cyanide (CN) toxicity is most commonly associated with smoke inhalation
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