CYANIDE TOXICITY
Inclusion Criteria: Any patient with smoke inhalation OR suspected cyanide ingestion, and severe symptoms suggesting cyanide toxicity, including ANY of the following: Altered mental state; Cardiac arrhythmia; Respiratory depression; Seizure; Hypotension without other clear etiology; Respiratory arrest; or Cardiac Arrest.
SPECIAL NOTE: Refer to the CYANIDE ANTIDOTE ADMINISTRATION Policy for additional guidance.
Basic Level
- Scene safety:
- Do not enter a scene where a potential exposure to cyanide may be encountered until cleared by appropriate agencies.
- If there is a suspected significant cyanide exposure, appropriate BSI and patient decontamination techniques should be implemented.
- Assess and support ABCs.
- Airway management:
- Pulse oximetry (SpO2 monitoring):
- Provide all patients with suspected cyanide toxicity with high-flow oxygen by tight fitting face mask.
- NOTE: Pulse oximetry in the patient suffering from cyanide toxicity may be unreliable
- Carbon monoxide (CO) co-oximetry:
- If available, SpCO should be measured.
Advanced Level
- Cardiac (ECG) monitoring:
- Implement continuous ECG monitoring for all patients being treated for cyanide toxicity.
- Quantitative ETCO2 monitoring:
- Implement continuous ETCO2 monitoring for all patients being treated for cyanide toxicity.
- Glucose:
- Perform a POC glucose analysis and treat accordingly on all patients being treated for cyanide toxicity.
- Vascular access:
- Hydroxocobalamin administration requires a dedicated IV or IO line; as such, a second IV or IO access may be needed.
- Hydroxocobalamin administration:
- If the patient meets criteria for administration of hydroxocobalamin as outlined above, dosing should be:
- ADULT: 5 g for adults, administered over 15 minutes.
- PEDIATRIC: 70 mg/kg, administered over 15 minutes.
- A second dose may be given, if needed, after 30 minutes (Adult - full dose; Pediatric - 35 mg/kg).
On-line Medical Control Options
- Any patient with smoke inhalation OR suspected cyanide toxicity and moderate symptoms may receive hydroxocobalamin in consultation with on-line medical direction.
- Any patient with smoke inhalation or suspected cyanide ingestion AND the confirmed presence of cyanide on-scene may receive hydroxocobalamin in consultation with on-line medical direction.
- Refractory hypotension:
- Vasoactive medications for refractory hypotension should be given in consultation with BioTel.
Additional considerations
- Effect on body fluids:
- Hydroxocobalamin will change the color of urine, sweat and tears to red. This is normal, and the provider, patient and onlookers should be notified of this.
- Effect on serum analysis:
- Hydroxocobalamin will alter evaluation of blood samples drawn after medication administration. Hospital providers should be notified of this.
- If there is a high suspicion for concomitant carbon dioxide exposure, proceed to the CARBON MONOXIDE EXPOSURE Guideline following completion of this guideline.