Acetonitrile

CAS RN: 75-05-8

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Treatment is symptomatic and supportive. Administer intravenous fluids and monitor carefully for evidence of more severe toxicity.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Treatment should include volume expansion, pressors as needed for hypotension, 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. Several patients with unrecognized acetonitrile exposure and cyanide toxicity have survived with ICU level supportive care (eg, volume expansion, pressor support, endotracheal intubation, and mechanical ventilation) in the absence of antidote administration.
  • C) DECONTAMINATION
    • 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 of benefit early after ingestion exposures. 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 the airway or are intubated.
  • D) AIRWAY MANAGEMENT
    • 1) Ensure adequate ventilation and perform endotracheal intubation early in patients with severe CNS depression.
  • E) CYANIDE ANTIDOTE
    • 1) A cyanide antidote, either hydroxocobalamin or the sodium nitrite/sodium thiosulfate kit, should be administered to symptomatic patients.
  • F) HYDROXOCOBALAMIN
    • 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.
  • G) CYANIDE ANTIDOTE KIT
    • 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. 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.
  • H) ENHANCED ELIMINATION
    • 1) Antidotes increase elimination, however, the role of hemodialysis is uncertain.
  • I) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Home observation should not be considered as even small volume exposures in initially asymptomatic patients have resulted in severe toxicity. Patients with inhalational exposures exposed in an industrial setting should seek health care as the amount and duration of exposure can be difficult to quantify.
    • 2) OBSERVATION CRITERIA: All patients with potential acetonitrile exposures 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.
  • J) PITFALLS
    • 1) Most poor outcomes are associated with a failure to recognize an acetonitrile containing product or failure to recognize the expected 2 to 13 hour delay in toxicity.
  • K) TOXICOKINETICS
    • 1) Cyanide concentrations in the serum typically become elevated 2 to 13 hours after exposure. The duration of toxicity is difficult to assess and may be prolonged by delay to care and worsening clinical condition rather than metabolic variation. Half-life of acetonitrile is 32 to 36 hours. Half-life of cyanide in cases of acetonitrile poisoning has been 15 to 44 hours.
  • L) DIFFERENTIAL DIAGNOSIS
    • 1) Acetone exposure, methemoglobinemia, carbon monoxide exposure, cyanide from another source.
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.
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