2-22 CYANIDE EXPOSURE

Any patient requiring ACLS care should have an ALS intercept if logistically possible

EMR - Emergency Medical Responder

1. Perform scene size-up and ensure crew safety.  In a hazardous materials incident, stage upwind of the incident and do not attempt to treat patients who have not been decontaminated.
2. Immediately remove patient from continued exposure
3. Assess vitals
4. If necessary, provide CPR as outlined in the Adult Cardiac Arrest: Cardio-Cerebral Resuscitation Protocol
5. Apply high flow oxygen via non-rebreather mask to any patient suspected of cyanide or carbon monoxide exposure
6. Minimize patient’s physical exertion to maximize oxygenation saturation
7. Call for ALS Intervention
8. Prepare for transport.  Note that any patient that requires decontamination must undergo proper decontamination procedures prior to transport.

EMT- Emergency Medical Technician  Perform/Confirm All Above Interventions

1. Ensure ALS Response is en route
2. Reassess vitals
3. Perform Glucometry and follow hypoglycemic protocol if indicated
4. Transport as early as possible

CONTACT MEDICAL CONTROL

AEMT – Advanced Emergency Medicine Tech   Perform/Confirm All Above Interventions

1. Initiate IV/IO NS, if approved, give NS fluid bolus, 500 ml wide open (do not delay transport) CONTACT MEDICAL CONTROL
2. Give additional NS fluid bolus, as directed

Intermediate  perform/confirm all above interventions

1. Attach cardiac monitor if not already done
2. Insert Advance Airway (Non-visualized or ETT) if not already done & confirm placement via capnography

CONTACT MEDICAL CONTROL

Paramedic  perform/confirm all above interventions

1. Ensure all above interventions have been carried out
2. For patients with known or suspected cyanide exposure AND severe symptoms (seizure activity, coma, or cardiopulmonary arrest) AND no contra-indications - initiate the Cyanokit Treatment Protocol without delay CONTACT MEDICAL CONTROL
3. For patients with known or suspected cyanide exposure and mild symptoms (vomiting, lightheaded, headache, etc) contact medical control to discuss initiation of the Cyanokit Treatment Protocol

Cyanokit Treatment Protocol – Paramedics Only

Purpose:  The Cyanokit® is indicated for the treatment of known or suspected cyanide poisoning. If clinical suspicion of cyanide poisoning is high, Cyanokit® should be administered without delay. Note, patients experiencing serious symptoms (persistent vomiting, altered mental status, or cardiopulmonary arrest) from smoke inhalation, particularly when in a confined space exposure (inside a house fire,) frequently have cyanide exposure with or without carbon monoxide exposure and should be considered for the Cyanokit®.

Appropriate Personnel: EMT Paramedics in approved services

Indications:

1. Known or suspected cyanide poisoning with severe symptoms
   1. Altered mental status, coma
   2. Seizure activity
   3. Cardiopulmonary arrest

Contraindications:

1. Signs of trauma or other findings incompatible with life.

Potential Candidates:

1. Smoke inhalation with the presence of persistent vomiting, lightheadedness, seizures, altered mental status, or cardiopulmonary arrest
2. Intentional or unintentional poisoning or ingestion of Laetrile (vitamin B17) or multiple fruit pits
3. Industrial exposure such as metal plating and recovery, plastics, industrial uses of hydrogen cyanide or medical complications from the use of sodium nitroprusside
4. Be aware that patients with cyanide poisoning may have normal pulse oximetry readings

Protocol:

1. Cyanokit® requires a separate intravenous line for administration.  There are a number of drugs and blood products that are incompatible with Cyanokit®.
2. Cyanokit® is packaged in two ways. Either one 5g vial or two 2.5g vials.  This protocol is for the one vial kit.
   1. One vial kit with 5g of hydroxocobalamin powder must be reconstituted with 200mL of normal saline.  This should be rotated or tipped for 60 seconds (not shaken) and administered through its own IV line (not used with any other medication) over 15 minutes.   This gives a final concentration of 5g/200mL.
3. Adult Dosing:  5g IV/IO administered over 15 minutes.
4. Pediatric Dosing:  70 mg/kg IV/IO (Max of 5g) administered over 15 minutes
5. The vial of hydroxocobalamin for injection is to be reconstituted with diluent (not provided with Cyanokit®) using the supplied sterile transfer spike.
   1. The recommended diluent is 0.9% Sodium Chloride injection (0.9% NaCl).
      1. Alternate solutions for dilution if NaCl not available:
         1. Lactated Ringers injection
         2. 5% Dextrose injection (D5W)
   2. The line on the vial label represents the volume of diluent. Following the addition of diluent to the lyophilized powder, the vial should be repeatedly  inverted or rocked, not shaken, for at least 60 seconds for the 5g bottles.
   3. Hydroxocobalamin solutions should be visually inspected for particulate matter and color prior to administration.
      1. If the reconstituted solution is not dark red or if particulate matter is seen after the solution has been appropriately mixed, the solution should not be administered to the patient and should be discarded.
6. Depending upon the severity of the poisoning and the clinical response, a second dose of 5g may be administered by IV/IO infusion for a total dose of 10g in adults. The rate of infusion for the second dose may range from 15 minutes (for patients in extremis) to two hours, as clinically indicated. Contact medical control for second dose instructions for pediatric patients.