Decemeber 1, 2023

Welcome to Pharmacy Phriday, week number 48 of 2023. It is difficult to comprehend that this year is almost at its end, but December has arrived, and so has the winter weather. With the increased cold comes increased use of our furnaces, heaters, etc., and our Fire and EMS agencies respond to more emergencies associated with these hazards. 

Carbon monoxide exposure comes to mind when we consider heating equipment using fossil fuels. Smoke inhalation and the exposure to toxic gases are a concern in structure fires. According to the NFPA, December, January, and February are the peak months for heating fires.

Carbon monoxide and hydrogen cyanide are sometimes referred to as the “toxic twins” of smoke inhalation. Both disrupt oxygen use at the cellular level. Carbon monoxide exposure can be measured in the prehospital setting fairly easily, but rapid testing is not available to determine cyanide exposure for smoke-exposed individuals. 

Treatment of cyanide poisoning in the prehospital field is frequently based on the history of the incident, a known exposure in an industrial setting, and evidence of smoke inhalation through signs and symptoms such as soot around the airway, decreased level of consciousness, hypotension, respiratory or cardiac arrest, or seizures.

This week’s focus of the Pharmacy Phriday article is on a special-use medication listed in your UH protocols that is sometimes carried by squads, or that may be found in various industrial settings where the use of cyanide or exposure to cyanide is common. Hydroxocobalamin, known more commonly as the “Cyanokit,” is an antidote used in cases of known or suspected cyanide poisoning.   

Cyanide is a hazard that a person can be exposed to via inhalation, ingestion, absorption, or injection. It can be found in various industries, such as mining, metal plating, plastics, and jewelry manufacturing, just to name a few. It can also be found in many common foods, such as fruit pits, almonds, and cabbage. Cyanide has also been used in suicide attempts and as a weapon in bioterrorism.   But more often, cyanide poisoning is associated with smoke inhalation (along with CO poisoning) due to exposure to fires in a residence or other enclosed space.

Once it is determined that cyanide is a known or suspected exposure, the Cyanokit should be administered as soon as possible.   There are no contraindications for its use in the emergency setting. 

The Cyanokit has a rapid onset of action, neutralizing cyanide without interfering with cellular oxygen use, and can be used in the prehospital setting safely along with other exposures such as carbon monoxide. The cyanide within the body is essentially bound up as cyanocobalamin and excreted through the kidneys.   In addition to the Cyanokit, treatment should include supportive care such as oxygen therapy, cardiac and respiratory support as needed, fluids, monitoring, seizure control, etc.  

The Cyanokit is administered as a 5-gram infusion over 15 minutes. Prior to administration, the kit requires mixing or reconstitution. Using a transfer spike included in the kit along with an IV bag of Normal Saline, 200 ml of NS is introduced into the vial of Hydroxocobalamin and then mixed by rocking and inverting for 60 seconds. Do not shake the mixture! Once mixed, the infusion is given using the supplied “vented” IV tubing (about 15ml/min). A separate IV line is required as many medications are not compatible with the Cyanokit, including benzos that may be administered for possible seizures. One dose is considered a starting dose, and a second dose may be required depending on the patient's response and the severity of the exposure.

Typical reactions to the Cyanokit include redness of the patient’s skin, eyes, urine, etc. Severe reactions can include allergic reactions, hypertension, chest pain, dyspnea, and GI symptoms. 

UH Protocols do not currently indicate the use of the Cyanokit for the pediatric patient.

Finally, remember your safety first. Do not become a victim in these cases. Remember that cyanide exposure can occur through many routes and may require various levels of PPE, including gloves, gowns, suits, and other forms of skin protection, as well as respirators or SCBA. Decontamination of the patient may also be a consideration.  

Watch HERE and follow HERE for further information on cyanide poisoning and the use of the Cyanokit.

Till next week, stay safe!!

Sincerely,



The UH EMS-I Team

University Hospitals

November 4, 2022

Dear Colleagues,

Welcome to Pharmacy Phriday, week number 44.  This week will focus on another of the special-use medications listed in your UH protocols.  Hydroxocobalamin, known more commonly as the “Cyanokit,” is an antidote used in cases of known or suspected cyanide poisoning.  It is a medication not provided in the UH drug boxes but is sometimes carried by fire departments for use on the scene of structure fires or can sometimes be found in various industrial settings where the use of cyanide or exposure to cyanide is common.   

Cyanide is a hazard that a person can be exposed to via inhalation, ingestion, absorption, or injection.  It can be found in various industries, such as mining, metal plating, plastics, and jewelry manufacturing, just to name a few.  It can also be found in many common foods, such as fruit pits, almonds, and cabbage. Cyanide has also been used in suicide attempts and as a weapon in bioterrorism.   But more often, cyanide poisoning is associated with smoke inhalation (along with CO poisoning) due to exposure to fires in a residence or other enclosed space. A recent NFPA report indicated that 46% of fires occurred in the five-month span from November to March. As November 2022 begins, it is reasonable to prepare for these types of incidents.

Carbon monoxide and hydrogen cyanide are sometimes referred to as the “toxic twins” of smoke inhalation. Both disrupt oxygen use at the cellular level.  Carbon monoxide exposure can be measured in the prehospital setting fairly easily, but rapid testing is not available to determine cyanide exposure for smoke-exposed individuals.  Some literature suggests the use of measuring lactate levels to help diagnose cyanide poisoning in suspected cases.  Recent developments have led to a test strip, that when used with a swab of the patient’s saliva, can detect thiocyanate, a natural response of the body in cyanide poisoning, and diagnose such poisoning.  But this is only in the testing and assessment phases and is not available for use as of yet. 

Treatment with the Cyanokit is frequently based on the history of the incident and evidence of smoke inhalation through signs and symptoms such as soot around the airway, decreased level of consciousness, hypotension, respiratory or cardiac arrest, or seizures.  Once determined that cyanide is a known or suspected exposure, the Cyanokit should be administered as soon as possible.   There are no contraindications for its use in the emergency setting. 

The Cyanokit has a rapid onset of action, neutralizing cyanide without interfering with cellular oxygen use, and can be used in the prehospital setting safely, along with other exposures such as carbon monoxide.  The cyanide within the body is essentially bound up as cyanocobalamin and excreted through the kidneys.   In addition to the Cyanokit, treatment should include supportive care such as oxygen therapy, cardiac and respiratory support as needed, fluids, monitoring, seizure control, etc.   

The Cyanokit is administered as a 5-gram infusion over 15 minutes.  Prior to administration, the kit requires mixing or reconstitution.  Using a transfer spike included in the kit along with an IV bag of Normal Saline, 200 ml of NS are introduced into the vial of Hydroxocobalamin and then mixed by rocking and inverting for 60 seconds.  Do not shake the mixture! Once mixed, the infusion is given using the supplied “vented” IV tubing (about 15ml/min).  A separate IV line is required as many medications are not compatible with the Cyanokit, including benzos that may be administered for possible seizures. One dose is considered a starting dose, and a second dose may be required depending on the patient’s response and the severity of the exposure.

Typical reactions to the Cyanokit include redness of the patient’s skin, eyes, urine, etc.  Severe reactions can include allergic reactions, hypertension, chest pain, dyspnea, and GI symptoms. 

UH Protocols do not currently indicate the use of the Cyanokit for the pediatric patient.

Finally, remember your safety first.  Do not become a victim in these cases.  Remember that cyanide exposure can occur through many routes and may require various levels of PPE, including gloves, gowns, suits, and other forms of skin protection, as well as respirators or SCBA.  Decontamination of the patient may also be a consideration. 

For further information on cyanide poisoning and the use of the Cyanokit, follows these links.

https://www.youtube.com/watch?v=bJEtw-4M-cE

https://cyanokit.com/

And remember, this weekend is the time change.  “Fall back” this Sunday at 0200 hours.  Since the topic this week included the mention of residential fires, we want to be sure to also remind everyone to “change your clock and check your batteries” in your smoke detectors!

Till next week, stay safe!!

Sincerely,

The UH EMS-I Team

University Hospitals