Management of Cyanide Poisoning

Decontamination 

• Gastrointestinal decontamination should be performed rapidly in cases of oral ingestion, as cyanide is quickly absorbed. 
• We suggest that a single dose of activated charcoal (AC) be administered (50 g in adults; 1 g/kg, up to 50 g maximum, in children). 
• There is no role for multiple doses of AC or cathartics, such as magnesium citrate or sorbitol. Charcoal should be withheld in nonintubated patients with a depressed mental status.
• Orogastric lavage is not recommended. It may be attempted only if ingestion occurred within 60 minutes of presentation and a large amount of cyanide is thought to be present in the upper gastrointestinal tract.

Cyanide Antidotes

• Antidotes to cyanide include hydroxocobalamin and sodium nitrite and sodium thiosulfate.
• Sodium thiosulfate may be given in combination with sodium nitrite or hydroxocobalamin, or may be given alone.
• These agents are administered intravenously.

Hydroxocobalamin 

• Because acts rapidly, does not adversely affect tissue oxygenation, and is relatively safe, many investigators recommend it be used as the first line agent in cyanide poisoning.

• Commonly used in conjunction with sodium thiosulfate, a combination shown to be effective and safe in severe cyanide poisoning.

  

Sodium nitrite

• Treatment with amyl nitrite or sodium nitrite is contraindicated in cases of potential carbon monoxide toxicity (eg, from a fire), until carbon monoxide toxicity has been excluded.

Sodium Thiosulphate

• Can be used alone for mild poisoning cases but should be used with sodium nitrite in severe poisoning cases.
• Intravenous route (for acute cyanide toxicity):
  • Adults: Give 12.5 g (50 mL of 25% w/v solution) at 2.5-5 mL/min.
  • Paediatric: Give 1.65 mL/kg up to 50 mL.
• Thiocyanate toxicity can develop in patients with renal impairment.

References 

1. Thompson, T. M. 153 Inhaled Toxins.

2. www.uptodate.com

3.  http://emedicine.medscape.com/article/814287-treatment#d11

4.https://www.moh.gov.sg/content/dam/moh_web/HPP/Pharmacists/cpg_pharmacy/management%20of%20poisoning%20-%20booklet.pdf