Cyanogen

CAS RN:460-19-5

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Patients with even brief or small exposures should be monitored extremely closely for signs of deterioration. Supplemental oxygen should be administered immediately with continuous monitoring of vital signs. Establish intravenous access immediately. An antidote kit should available at the bedside. Worsening or severe acidosis, hypotension, seizures, dysrhythmias and coma indicate a more severe poisoning.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Elevated lactate, increased anion gap metabolic acidosis, and an elevated venous oxygen saturation all suggest a significant cyanide exposure. Manage airway early. Patients who are comatose or severely ill due to suspected cyanide poisoning should be administered a cyanide antidote kit. In addition, standard ACLS or PALS therapy should be provided to manage symptoms. Administer sodium bicarbonate for severe acidemia.
  • C) DECONTAMINATION
    • 1) PREHOSPITAL: Prehospital activated charcoal can be considered for large ingestions in which there will be a delay in definitive healthcare; however, a poison center should initially be consulted.
    • 2) HOSPITAL: DERMAL EXPOSURE: Remove clothes and wash the skin with water. Healthcare providers should use personal protective equipment if there could be a dermal exposure. Activated charcoal binds poorly to cyanide salts; however, the lethal dose is so small that the use of activated charcoal should be considered in a patient that presents with one hour of an oral ingestion
  • D) AIRWAY MANAGEMENT
    • 1) Patients who are comatose or with altered mental status need early endotracheal intubation and mechanical ventilation.
  • E) CYANIDE ANTIDOTE
    • 1) SUMMARY: A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to symptomatic patients. If cyanide toxicity develops concurrent with carbon monoxide poisoning (e.g., closed space fire), hydroxocobalamin is the preferred antidote. It that is not available, sodium thiosulfate may be used alone. Use of amyl nitrite or sodium nitrite will cause methemoglobinemia, further reducing oxygen carrying capacity.
    • 2) HYDROXOCOBALAMIN
      • a) ADULT: Administer 5 g IV over 15 minutes. A second dose may be given (infused over 15 to 120 minutes) in patients with severe toxicity. PEDIATRIC: A dose of 70 mg/kg has been used. Hydroxocobalamin forms cyanocobalamin which is a nontoxic, water soluble metabolite that is eliminated in the urine. It is generally safer and easier to use than other antidotes (i.e., nitrite and thiosulfate kits). Sodium thiosulfate may also be administered with hydroxocobalamin, but it is not part of the kit. ADVERSE EFFECTS: Flushing is common. Hydroxocobalamin is bright red and causes discoloration of the skin, urine, and serum. It can also interfere with many colorimetric based tests.
    • 3) CYANIDE ANTIDOTE KIT
      • a) An alternative, a sodium nitrite/sodium thiosulfate kit, is administered as follows: SODIUM NITRITE: ADULT: Administer 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). The dose may be lowered if the patient is severely anemic, but administration should not be delayed for laboratory results. Blood methemoglobin levels should be monitored for 30 to 60 minutes following the infusion to prevent severe toxicity. If methemoglobin concentration is greater than 30%, it should likely be reversed with methylene blue. Nitrites may also cause vasodilatory effects which may contribute to hypotension. 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: Administer 50 mL (12.5
      • g) of a 25% solution IV; 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. This agent enhances conversion of cyanide to thiocyanate which is eliminated in the urine. Patients with renal failure may need dialysis to eliminate thiocyanate. ALTERNATE ANTIDOTES: Kelocyanor
  • (R) (dicobalt-EDTA) and 4-DMAP (4-dimethylaminophenol) are among the cyanide antidotes in clinical use outside the US.
  • F) METHEMOGLOBINEMIA
    • 1) Initiate oxygen therapy. Treat with methylene blue if patient is symptomatic (usually at methemoglobin concentrations greater than 20% to 30% or at lower concentrations in patients with anemia, underlying pulmonary or cardiovascular disease). METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg.
  • G) ENHANCED ELIMINATION
    • 1) Antidotes increase elimination, however, the role of hemodialysis is uncertain.
  • H) PATIENT DISPOSITION
    • 1) HOME CRITERIA: There is no role for home management of cyanide exposure.
    • 2) OBSERVATION CRITERIA: Any exposure to cyanide salts or cyanide gas should be referred to a healthcare facility. Patients who remain asymptomatic with normal laboratory studies can be discharged after 6 hours.
    • 3) ADMISSION CRITERIA: Any patient with symptomatic poisoning should be admitted to an intensive care unit.
    • 4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing symptomatic patients.
  • I) PITFALLS
    • 1) Treatment should not be delayed for laboratory results if a cyanide exposure is strongly suspected. If cyanide toxicity develops concurrent with carbon monoxide poisoning (e.g., closed space fire), hydroxocobalamin is the preferred antidote. It that is not available, sodium thiosulfate may be used alone. Use of amyl nitrite or sodium nitrite will cause methemoglobinemia, further reducing oxygen carrying capacity.
  • J) PHARMACOKINETICS
    • 1) The volume of distribution is not completely known, but cyanide is widely distributed to organs and tissues. The half-life for conversion of a nonlethal dose of cyanide to thiocyanate is 20 to 60 minutes, but the elimination half-life is not completely known.
  • K) TOXICOKINETICS
    • 1) The amount, duration of exposure, route of exposure and premorbid conditions of the patient will affect the time and severity of the poisoning. Symptoms typically begin within 5 minutes of a significant inhalational exposure and within 30 minutes of a significant oral exposure.
  • L) DIFFERENTIAL DIAGNOSIS
    • 1) Carbon monoxide and hydrogen sulfide gas exposures may cause transient loss consciousness with apnea, coma, and acidosis. The differential of an elevated anion gap acidosis is otherwise extremely broad and consists of toxicologic and non-toxicologic causes.
0.4.3 INHALATION EXPOSURE
  • 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) Administer 100% oxygen, establish secure large bore IV.
  • C) CYANIDE ANTIDOTE SUMMARY
    • 1) A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to patients with symptomatic poisoning. If cyanide toxicity develops concurrent with carbon monoxide poisoning (e.g., closed space fire), hydroxocobalamin is the preferred antidote. It that is not available, sodium thiosulfate may be used alone. Use of amyl nitrite or sodium nitrite will cause methemoglobinemia, further reducing oxygen carrying capacity.
  • D) HYDROXOCOBALAMIN
    • 1) ADULT: Administer 5 g IV over 15 minutes. A second dose may be given (infused over 15 to 120 minutes) in patients with severe toxicity. PEDIATRIC: A dose of 70 mg/kg has been used. Hydroxocobalamin forms cyanocobalamin which is a nontoxic, water soluble metabolite that is eliminated in the urine. It is generally safer and easier to use than other antidotes (i.e., nitrite and thiosulfate kits). Sodium thiosulfate may also be administered with hydroxocobalamin, but it is not part of the kit. ADVERSE EFFECTS: Flushing is common. Hydroxocobalamin is bright red and causes discoloration of the skin, urine, and serum. It can also interfere with many colorimetric based tests.
  • E) CYANIDE ANTIDOTE KIT
    • 1) An alternative, a sodium nitrite/sodium thiosulfate kit, is administered as follows: SODIUM NITRITE: ADULT: Administer 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). The dose may be lowered if the patient is severely anemic, but administration should not be delayed for laboratory results. Blood methemoglobin levels should be monitored for 30 to 60 minutes following the infusion to prevent severe toxicity. If methemoglobin concentration is greater than 30%, it should likely be reversed with methylene blue. Nitrites may also cause vasodilatory effects which may contribute to hypotension. 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: Administer 50 mL (12.5
      • g) of a 25% solution IV; 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. This agent enhances conversion of cyanide to thiocyanate which is eliminated in the urine. Patients with renal failure may need dialysis to eliminate thiocyanate. ALTERNATE ANTIDOTES: Kelocyanor
  • (R) (dicobalt-EDTA) and 4-DMAP (4-dimethylaminophenol) are among the cyanide antidotes in clinical use outside the US.
  • F) METHEMOGLOBINEMIA
    • 1) Initiate oxygen therapy. Treat with methylene blue if patient is symptomatic (usually at methemoglobin concentrations greater than 20% to 30% or at lower concentrations in patients with anemia, underlying pulmonary or cardiovascular disease). METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg.
0.4.4 EYE EXPOSURE
  • A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) DECONTAMINATION: 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. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    • 2) While cyanide can be absorbed through intact skin, most reported cases have involved whole-body immersion in cyanide solutions or large-area burns with molten cyanide solutions. Most nitrile compounds are well absorbed through intact skin, and may cause delayed onset of symptoms following exposure by this route.
    • 3) Administer 100% oxygen, establish secure large bore IV.
    • 4) CYANIDE ANTIDOTE SUMMARY
      • a) A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to patients with symptomatic poisoning. If cyanide toxicity develops concurrent with carbon monoxide poisoning (e.g., closed space fire), hydroxocobalamin is the preferred antidote. It that is not available, sodium thiosulfate may be used alone. Use of amyl nitrite or sodium nitrite will cause methemoglobinemia, further reducing oxygen carrying capacity.
    • 5) HYDROXOCOBALAMIN
      • a) ADULT: Administer 5 g IV over 15 minutes. A second dose may be given (infused over 15 to 120 minutes) in patients with severe toxicity. PEDIATRIC: A dose of 70 mg/kg has been used. Hydroxocobalamin forms cyanocobalamin which is a nontoxic, water soluble metabolite that is eliminated in the urine. It is generally safer and easier to use than other antidotes (i.e., nitrite and thiosulfate kits). Sodium thiosulfate may also be administered with hydroxocobalamin, but it is not part of the kit. ADVERSE EFFECTS: Flushing is common. Hydroxocobalamin is bright red and causes discoloration of the skin, urine, and serum. It can also interfere with many colorimetric based tests.
    • 6) CYANIDE ANTIDOTE KIT
      • a) An alternative, a sodium nitrite/sodium thiosulfate kit, is administered as follows: SODIUM NITRITE: ADULT: Administer 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). The dose may be lowered if the patient is severely anemic, but administration should not be delayed for laboratory results. Blood methemoglobin levels should be monitored for 30 to 60 minutes following the infusion to prevent severe toxicity. If methemoglobin concentration is greater than 30%, it should likely be reversed with methylene blue. Nitrites may also cause vasodilatory effects which may contribute to hypotension. A second dose, one-half of the first dose, may be administered 30 minutes later if there is inadequate clinical response. SODIUM THIOSULFATE: Follow sodium nitrite with IV sodium thiosulfate. ADULT: Administer 50 mL (12.5
      • g) of a 25% solution IV; 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. This agent enhances conversion of cyanide to thiocyanate which is eliminated in the urine. Patients with renal failure may need dialysis to eliminate thiocyanate. ALTERNATE ANTIDOTES: Kelocyanor
  • (R) (dicobalt-EDTA) and 4-DMAP (4-dimethylaminophenol) are among the cyanide antidotes in clinical use outside the US.
    • 7) METHEMOGLOBINEMIA
      • a) Initiate oxygen therapy. Treat with methylene blue if patient is symptomatic (usually at methemoglobin concentrations greater than 20% to 30% or at lower concentrations in patients with anemia, underlying pulmonary or cardiovascular disease). METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg.
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