Cyanide Treatment

[18G]

I have been really interested in the recent recognition of the importance in treating cyanide toxicity in smoke inhalation patients so wanted to start a discussion on the topic.

I just read the studies done in France and was impressed at the benefits of their EMS people treating smoke inhalation with Hydroxocobalamin. All the focus in the US has been on treating smoke inhalation patients for CO poisoning. Perhaps little focus has been on cyanide since there was not a suitable antidote for field use and empirical administration was not always advisable in the field.

To start off, how many providers function in EMS systems that stock Hydroxocobalamin? And if so, how was your experience with it?

Also, I have seen lactic acid monitors that look similar to glucometers that apparently pro athletes use.... and there has been interest in using them as part of recognizing sepsis. With the metabolic acidosis caused by cyanide toxicity, do you see benefit with measuring lactate level in the field to gauge degree of cyanide toxicity?

The ability to treat something as deadly as cyanide with a medication that has been shown to have a great safety profile with no adverse effects in healthy volunteers to me is an awesome advancement to EMS care.

 

[STXmedic]

Our system here uses the CyanoKits. We were given 60 via grant money (from what I hear, they are VERY expensive). Protocol dictates that anybody pulled from a fire is to be immediately administered the drug. Dosing is very easy! Adults get both drip vials, pedis get a single drip vial (looks similar to a nitro drip). I know of it being used twice so far, both with positive pt outcomes. As a side note, you know if a patient has been given hydroxocobalamin because a side effect is that they end up looking like oompa loompas

 

[18G]

I don't know how accurate the source is but one place online mentioned that a single dose of the antidote was around $700. If anyone has verified cost I would be interested in knowing.

 

[brentoli]

First google hit:
Dey Laboratories Cyanokit Cyanide Antidote Kit

SKU: MME-83465 Retail Price: $1,140.80
Our LOW Price: $843.20
You Save: $297.60 (26%)

 

[STXmedic]

I don't know how accurate the source is but one place online mentioned that a single dose of the antidote was around $700. If anyone has verified cost I would be interested in knowing.

I'm on shift tomorrow. I'll try and find out more for you when I go in.

 

[18G]

Until the patent expires I'm sure it will remain on the expensive side and won't be feasible for stocking on every EMS unit. Perhaps just on Supervisor / Duty Office vehicles.

The good thing though is that it has a shelf life of 36 months.

Here is the manufactures website which has a lot of good info on administration. If you read the package insert or prescribing information you can get some great info on the drug and cyanide toxicity itself.

http://www.cyanokit.com/index.cfm

 

[zmedic]

I think like a lot of things in EMS it comes down to the probability of a given ambulance using a drug/piece of equipment in a given year. So places like New York City where they have lots of working fires, it makes sense to have this equipment on all the ambulances. Other places maybe should think about just having a few kits at the hospital if they haven't had a fire victim in a few years. Same thing with the Mark 1 kits, after 9/11 every one and their brother was running around with a kit in case of nerve agent attack. Again makes sense for high risk responders and targets, not sure if you really need it for small town america.

Also here in New York they are using Thiosulfate along with the Hydroxocobalamin.

 

[18G]

Again makes sense for high risk responders and targets, not sure if you really need it for small town america.

Fire and smoke inhalation is an everyday possibility for every single one of us regardless if we live in a big city or small, rural community. Given the lethal nature of cyanide toxicity, I think every EMS service should be setup to have the antidote available on every fire scene.

Treatment of cyanide poisoning is extremely time sensitive and patients do not have the benefit of waiting until they arrive at the hospital to receive the antidote. When cyanide is present, all the intubation and oxygenation in the world won't do a bit of good since the cells are blocked from using it.

 

[FFMedic75]

I recently participated in an AHLS class. There was some time spent on this topic. One important point is that most Cyanide kits use Sodium Nitrate to create Methemoglobin to bind to the Cyanide. It is very dangerous to create large amounts Methemoglobin in a patient who already has a high Carboxyhemoglobin level. Since CO is the major byproduct of fire this creates several issues. Being able to monitor SPCO and SPMet levels (such as with a RAD 57) can be helpful however they recommended using Hydroxocobalamin instead of the standard kit. Hydroxocobalamin is significantly more expensive but the trials in Europe have found it to be better suited for smoke inhalation. Just some food for thought

 

[Aidey]

^^^ That is what we have available, the only issue is that it hasn't been approved for use in children. Or else it is approved with no dosing instructions. Either way, we aren't supposed to use it in peds.

 

[STXmedic]

Our protocol states that the pediatric dose for hydrococobalamin is half the dose for an adult (one of the two drips it comes with). I need to check for an age minimum though.

 

[FFMedic75]

I think 70mg/kg is the peds dose, I'm not sure if it is FDA approved for kids. You could always call Poison Control on a nonemergency line they can probably tell you.

 

[Aidey]

I double checked, and it says it hasn't been approved for use in kids, but that the 70mg/kg dose has been used outside of the US.

 

[STXmedic]

I just went to recheck. Quote from my smops book, "Pediatric dose: 70mg/kg IV - Max dose 5 grams. Administer at 10-15cc/min". San Antonio EMS. Strange for us to be doing it, as we aren't usually considered a "Progressive" system.

 

[18G]

From the Cyanokit package insert.

8.4 - Pediatric Use
Safety and effectiveness of Cyanokit have not been established in this
population. In non-US marketing experience, a dose of 70 mg/kg has been
used to treat pediatric patients.