Friday, March 24, 2017

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

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