Cyanide toxicity and/or Carbon monoxide

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This may be a very basic question, but maybe could clear up some gaps in my knowledge:

If you have a patient come in from a fire with altered level of consciousness... (after all the ABCIVO2 stuff) when would you break out the cyanide kit? For any comatose patient after a fire? If they are hypotensive? If there is an elevated lactate?

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Possibly after the blood gas.

If there's significant carboxyhemoglobin, then I'll probably not entertain cyanide unless they have other evidence of that toxidrome.
 
This may be a very basic question, but maybe could clear up some gaps in my knowledge:

If you have a patient come in from a fire with altered level of consciousness... (after all the ABCIVO2 stuff) when would you break out the cyanide kit? For any comatose patient after a fire? If they are hypotensive? If there is an elevated lactate?

The toxidrome for significant cyanide poisoining is dead. d=)

If they're not dead, then possible mild-mod poisoning. Look at the gas - big ol lactate, then consider it... CN poisons mitochondria, causing profound lactic acidosis from anaerobic metabolism.

You want to be careful with empiric treatment b/c if you have the old kit (NaNO3 + thiosulfate), the first step is to induce MetHgb - which is bad in CO poisoning... CO causes functional anemia by impairing O2 delivery, as does MetHgb.

If you have cyanokit (b12a), then no MetHgb, and OK to give to a CO patient.

Savvy?
-d


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The toxidrome for significant cyanide poisoining is dead. d=)

If they're not dead, then possible mild-mod poisoning. Look at the gas - big ol lactate, then consider it... CN poisons mitochondria, causing profound lactic acidosis from anaerobic metabolism.

You want to be careful with empiric treatment b/c if you have the old kit (NaNO3 + thiosulfate), the first step is to induce MetHgb - which is bad in CO poisoning... CO causes functional anemia by impairing O2 delivery, as does MetHgb.

If you have cyanokit (b12a), then no MetHgb, and OK to give to a CO patient.

Savvy?
-d


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Are there many places that still don't have hydroxocobalamin? Honestly though, come to think of it, I have no idea whether we do or not.
 
Are there many places that still don't have hydroxocobalamin? Honestly though, come to think of it, I have no idea whether we do or not.

Believe it or not, yes... cost constraints with low frequency of use in most shops = not on formulary.

-d

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Keep in mind that hydroxocobalamin will induce a red color to the serum and other body fluids. While mostly harmless, it can interfere with colorometric assays.

If I didn't have hydroxocobalamine and was really afraid of cyanide in the face of CO poisoning, I'd just use the thiosulfate component. I'd also want to see a significant disparity between the lactic acid and CO levels.
 
If you have hydroxocobalamin you should probably give it to all fire victims with altered mental status. These days, most fires produce significant levels of cyanide as well as carbon monoxide. (Cyanide is produced when plastics and certain other synthetic materials are burned; carbon monoxide is produced when organic materials are incompletely combusted in a relatively oxygen poor environment.) Here hydroxocobalamin is given pre-hospital to all these patients.
 
Are yall seeing or aware of significant cyanide poisoning in the absence of significant CO?
 
Every cardiac arrest from a fire is presumed to have cyanide toxicity as a potential reversible cause; hydroxocobalamin is given prehospital, and we work them longer than most out-of-hospital arrests, just in case.
 
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