CAS RN:107-13-1

Treatment Overview

    • 1) Treatment is symptomatic and supportive. Administer intravenous fluids and monitor carefully for evidence of more severe toxicity. Correct any significant fluid and/or electrolyte abnormalities in patients with severe diarrhea and/or vomiting.
    • 1) Treatment should include ventilatory support and hydroxocobalamin or the cyanide antidote kit. Seizures should be considered an indication of severe toxicity and should be treated with benzodiazepines and hydroxocobalamin. Consider neurologic consult and continuous EEG monitoring for the sedated, chemically paralyzed, and intubated patient.
    • 1) PREHOSPITAL: Prehospital gastrointestinal decontamination is not recommended due to the potential for seizures and profound depression and subsequent aspiration risk.
    • 2) HOSPITAL: Activated charcoal may be beneficial if administered shortly after oral exposure. However, these patients are at risk for aspiration due to the potential for seizures and profound CNS depression. Activated charcoal should be reserved for the awake, alert, non-seizing patient, or the intubated patient. Consider orogastric lavage for patients with very recent ingestions who are alert and can protect their airway or are intubated.
    • 1) Ensure adequate ventilation and perform endotracheal intubation early in patients with severe CNS depression.
    • 1) A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to symptomatic patients.
    • 1) Hydroxocobalamin should be given if any laboratory or clinical signs or symptoms of cyanide toxicity develop. ADULT: Administer 5 g (two 2.5 g vials, each reconstituted with 100 mL sterile 0.9% saline) as an IV infusion over 15 minutes. For severe poisoning, a second dose of 5 g may be infused intravenously over 15 minutes to 2 hours, depending on the patient's condition. PEDIATRIC: Limited experience; a dose of 70 mg/kg has been used in pediatric patients.
    • 1) An alternative, a sodium nitrite/sodium thiosulfate kit, is administered as follows: SODIUM NITRITE: ADULT: 300 mg (10 mL of 3% solution) IV at a rate of 2.5 to 5 mL/min; PEDIATRIC: (with normal hemoglobin concentration) 0.2 mL/kg of a 3% solution (6 mg/kg) IV at a rate of 2.5 to 5 mL/min, not to exceed 10 mL (300 mg). A second dose, one-half of the first dose, may be administered 30 minutes later if there is inadequate clinical response. Use with caution if carbon monoxide poisoning is also suspected. SODIUM THIOSULFATE: Follow sodium nitrite with IV sodium thiosulfate. ADULT: 50 mL (12.5
      • g) of a 25% solution; PEDIATRIC: 1 mL/kg of a 25% solution (250 mg/kg), not to exceed 50 mL (12.5
      • g) total dose. A second dose, one-half of the first dose, may be administered if signs of cyanide toxicity reappear. ALTERNATE ANTIDOTES: Kelocyanor
  • (R) (dicobalt-EDTA) and 4-DMAP (4-dimethylaminophenol) are among the cyanide antidotes in clinical use outside the US.
    • 1) Antidotes increase elimination, however, the role of hemodialysis is uncertain.
    • 1) HOME CRITERIA: Home observation should not be considered, as even a small volume exposure in an initially asymptomatic patient may result in severe toxicity. A patient with an inhalational exposure in an industrial setting should seek medical care as the amount and duration of exposure can be difficult to quantify.
    • 2) OBSERVATION CRITERIA: All patients with a potential acrylonitrile exposure should be referred to a healthcare facility.
    • 3) ADMISSION CRITERIA: Patients should be admitted to an ICU setting and monitored for at least 24 hours as toxicity is expected to be delayed while cyanide is being produced via hepatic metabolism.
    • 4) CONSULT CRITERIA: Consult a medical toxicologist or poison center for any patient with significant toxicity or in whom the diagnosis is unclear.
    • 1) Acrylonitrile is readily absorbed by the inhalation, ingestion, and dermal route. Absorption was shown to be 90% to 98% following oral or inhalational exposure and was reported to be rapid. In human volunteers exposed to airborne concentrations of 5 or 10 mg/m(
    • 3) of acrylonitrile, 52% of the inhaled dose was retained. Acrylonitrile was absorbed through the skin of the forearm of workers at a rate of 0.6 mg/cm(2)/hr . Metabolism of acrylonitrile follows 2 pathways: conjugation with glutathione and oxidation by cytochrome P450, resulting in formation of the epoxide 2-cyanoethylene oxide. In humans, detoxification of 2-cyanoethylene oxide occurs via the epoxidehydrolase pathway. Acrylonitrile is metabolized to a lesser extent in humans than in rodents; therefore, cyanide toxicity may play a lesser role in humans than toxicity of the parent compound or its more proximate metabolites.
    • 1) Acetone exposure, methemoglobinemia, carbon monoxide exposure, cyanide from another source.
  • A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
  • B) OXYGEN: Administer 100% oxygen and establish vascular accesses.
  • A) Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature normal saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist, an ophthalmologic examination should be performed.
    • 1) Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. If pain and irritation persist, evaluation at a healthcare facility may be needed.
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