Hydrogen Cyanide Poisoning Medication

  • Author: Lewis S Nelson, MD, FACEP, FAACT, FACMT; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Dec 9, 2011
 

Medication Summary

The key medications for hydrogen cyanide (HCN) poisoning are cyanide antidotes. Hydroxocobalamin (HCO, vitamin B-12) is the first-line therapy for cyanide toxicity. It functions by binding cyanide to its cobalt ion to form cyanocobalamin, which is essentially nontoxic and is cleared renally. HCO can be combined with sodium thiosulfate administration for accelerated detoxification. The nitrite-containing components of a cyanide antidote kit must be used with caution because they may result in significant hypotension and cardiovascular collapse, in addition to generating consequential levels of methemoglobin. However, in cases of smoke inhalation in which cyanide toxicity is suspected, administration of sodium thiosulfate is safe.

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Antidotes

Class Summary

Administration of antidotes, which counteract the toxic effects of cyanide, is critical for life-threatening intoxication. The first-line therapy is hydroxocobalamin. Alternatively, the Taylor (formerly Lily or Pasadena) Cyanide Antidote Package contains amyl nitrite, sodium nitrite, and sodium thiosulfate.

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Hydroxocobalamin (vitamin B12a)

 

Hydroxocobalamin complexes with cyanide to form nontoxic cyanocobalamin (vitamin B12); its disadvantages are that a large dose is required for antidotal efficacy and that it is available in the United States only in very dilute solutions.

It can cause transient hypertension, allergic reactions (rarely including anaphylaxis and angioedema), and a reddish discoloration of body fluids.

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Amyl nitrite

 

Amyl nitrite pearls can be crushed and inhaled by a spontaneously breathing patient or ventilated into an apneic patient using a bag-valve-mask device; this is a temporizing measure until intravenous (IV) access can be established. Due to the volatile nature of this compound, rescuers should ensure that they themselves have an adequate fresh air supply and can maintain a sufficient distance from the amyl nitrite source.

Sodium nitrite

 

Sodium nitrite is the favored methemoglobin generator of the Cyanide Antidote Kit once IV access is established.

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Sodium thiosulfate

 

Sodium thiosulfate donates sulfur, which is used as a substrate by rhodanese and other sulfurtransferases for detoxification of cyanide to thiocyanate. It can be administered with hydroxocobalamin in severe cases.

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Activated charcoal (Actidose-Aqua, Ez-Char, Charcoal Plus DS)

 

Activated charcoal binds cyanide poorly; 1 g of charcoal adsorbs only 35 mg of cyanide. Nonetheless, a 1-g/kg dose of charcoal could potentially bind a lethal dose of cyanide and, given its low risk profile, charcoal should be administered as soon as possible following oral ingestion of cyanide salts or organic cyanides.

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Contributor Information and Disclosures
Author

Lewis S Nelson, MD, FACEP, FAACT, FACMT  Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Attending Physician, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center and New York Harbor Healthcare System

Lewis S Nelson, MD, FACEP, FAACT, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Colleen M Rivers, MD  Senior Fellow in Medical Toxicology, New York City Poison Control Center, Bellevue Hospital Center

Disclosure: Nothing to disclose.

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Andre Pennardt, MD, FACEP, FAAEM, FAWM  Clinical Associate Professor of Emergency Medicine, Medical College of Georgia; Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Departments of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center

Andre Pennardt, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US, International Society for Mountain Medicine, National Association of EMS Physicians, Special Operations Medical Association, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Additional Contributors

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Suzanne White, MD Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

Disclosure: Nothing to disclose.

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  16. Kirk MA, Gerace R, Kulig KW. Cyanide and methemoglobin kinetics in smoke inhalation victims treated with the cyanide antidote kit. Ann Emerg Med. Sep 1993;22(9):1413-8. [Medline].

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