![]() ![]() Sodium thiosulfate: 12.5 g (50 mL of a 25% solution) may repeat at one-half the original dose if symptoms of cyanide toxicity return Sodium nitrite: 300 mg (10 mL of a 3% solution) may repeat at one-half of the original dose if symptoms of cyanide toxicity returnĪlternatively, in patients who are unable to tolerate significant methemoglobinemia (eg, patients with comorbidities that compromise oxygen delivery, such as heart disease, lung disease), dosing may be based on hemoglobin levels (when rapid bedside testing is available) to prevent fatal methemoglobinemia see table (Berlin, 1970): Consider alternative therapeutic approaches in patients known to have diminished oxygen or cardiovascular reserve (eg, smoke inhalation victims, preexisting anemia, cardiac or respiratory compromise), and in those at higher risk of developing methemoglobinemia (eg, congenital methemoglobin reductase deficiency) as they are at greater risk of potentially life-threatening adverse events related to the use of sodium nitrite.Ĭyanide poisoning: IV: Note: Administer sodium nitrite first, followed immediately by the administration of sodium thiosulfate. Because of these risks, sodium nitrite should be used to treat acute life-threatening cyanide poisoning and should be used with caution in patients in whom the diagnosis of cyanide poisoning is uncertain.Ĭlosely monitor patients to ensure adequate perfusion and oxygenation during treatment with sodium nitrite. Hypotension and methemoglobin formation can occur concurrently or separately. Sodium nitrite causes hypotension and methemoglobin formation, which diminishes oxygen-carrying capacity. Hydroxocobalamin is an antidote that seems to have many of the characteristics of the ideal cyanide antidote: rapid onset of action, neutralizes cyanide without interfering with cellular oxygen use, tolerability and safety profiles conducive to prehospital use, safe for use with smoke-inhalation victims, not harmful when administered to non-poisoned patients, easy to administer.Sodium nitrite can cause serious adverse reactions and death in humans, even at doses less than twice the recommended therapeutic dose. Hydroxocobalamin differs from these antidotes in that it has not been associated with clinically significant toxicity in antidotal doses. The potential for serious toxicity limits or prevents the use of the Cyanide Antidote Kit, dicobalt edetate, and 4-dimethylaminophenol in prehospital empiric treatment of suspected cyanide poisoning. ![]() The data available to date do not suggest obvious differences in efficacy among antidotes, with the exception of a slower onset of action of sodium thiosulfate (administered alone) than of the other antidotes. Each of the antidotes shows evidence of efficacy in animal studies and clinical experience. This paper reviews preclinical and clinical data on available cyanide antidotes and considers the profiles of these antidotes relative to properties of a hypothetical ideal cyanide antidote. ![]() ![]() Critical assessment of cyanide antidotes is needed to aid in therapeutic and administrative decisions that will improve care for victims of cyanide poisoning (particularly poisoning from enclosed-space fire-smoke inhalation), and enhance readiness for cyanide toxic terrorism and other mass-casualty incidents. The international medical community lacks consensus about the antidote or antidotes with the best risk-benefit ratio. Cyanide has several antidotes, with differing mechanisms of action and diverse toxicological, clinical, and risk-benefit profiles. ![]()
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