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

  1. Scene safety:
    1. Do not enter a scene where a potential exposure to cyanide may be encountered until cleared by appropriate agencies.
    2. If there is a suspected significant cyanide exposure, appropriate BSI and patient decontamination techniques should be implemented.
  2. Assess and support ABCs.
  3. Airway management:
    1. Pulse oximetry (SpO2 monitoring):
      1. Provide all patients with suspected cyanide toxicity with high-flow oxygen by tight fitting face mask.
      2. NOTE: Pulse oximetry in the patient suffering from cyanide toxicity may be unreliable
    2. Carbon monoxide (CO) co-oximetry:
      1. If available, SpCO should be measured.

Advanced Level

  1. Cardiac (ECG) monitoring:
    1. Implement continuous ECG monitoring for all patients being treated for cyanide toxicity.
  2. Quantitative ETCO2 monitoring:
    1. Implement continuous ETCO2 monitoring for all patients being treated for cyanide toxicity.
  3. Glucose:
    1. Perform a POC glucose analysis and treat accordingly on all patients being treated for cyanide toxicity.
  4. Vascular access:
    1. Hydroxocobalamin administration requires a dedicated IV or IO line; as such, a second IV or IO access may be needed.
  5. Hydroxocobalamin administration:
    1. If the patient meets criteria for administration of hydroxocobalamin as outlined above, dosing should be:
      1. ADULT: 5 g for adults, administered over 15 minutes.
      2. PEDIATRIC: 70 mg/kg, administered over 15 minutes.
    2. A second dose may be given, if needed, after 30 minutes (Adult - full dose; Pediatric - 35 mg/kg).

On-line Medical Control Options

  1. Any patient with smoke inhalation OR suspected cyanide toxicity and moderate symptoms may receive hydroxocobalamin in consultation with on-line medical direction.
  2. 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.
  3. Refractory hypotension:
    1. Vasoactive medications for refractory hypotension should be given in consultation with BioTel.

Additional considerations

  1. Effect on body fluids:
    1. 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.
  2. Effect on serum analysis:
  3. Hydroxocobalamin will alter evaluation of blood samples drawn after medication administration.  Hospital providers should be notified of this.
  4. If there is a high suspicion for concomitant carbon dioxide exposure, proceed to the CARBON MONOXIDE EXPOSURE Guideline following completion of this guideline.