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Previous by Date: Subject: Re: Laboratory medical oversight Date: Thu, 18 Mar 2010 07:57:51 -0400 Author: Cat Conley |
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All the medications found in the 2 "cyanide antidote kits" available in the
US are prescription medications --their use must be authorized by a licens
ed physician.
The "old" Lilly/Pasadena/Taylor Cyanide Antidote Kit (CAK) contains 3 medic
ations: amyl nitrite perles which can be administered by inhalation
until intravenous access is established, and sodium nitrite and sodium t
hiosulfate for intravenous administration. The CAK has been in use
since the 1930s and has been shown to be efficacious for acute, severe cy
anide poisoning. Its drawbacks are that the 2 nitrite components ar
e both methemoglobin formers (produce non-oxygen transporting methemoglobin
with the iron moiety in the +3 rather than the normal +2 state) and can ca
use significant hypotension, especially if the sodium nitrite component i
s administered too rapidly intravenously, resulting in vasodilation.
; Many medical toxicologists feel that these adverse effects render the n
itrites unsuitable for use in situations where the diagnosis of cyanide poi
soning is unclear (unknown chemical exposure, enclosed-space smoke inhala
tion).
The "new" cyanide antidote kit (Cyanokit(R)) contains hydroxocobalamin as a
lyophylized powder to be prepared with normal saline or other suitable ste
rile IV solution at the time of use. Hydroxocobalamin does not indu
ce methemoglobinemia and does not cause hypotension. Through a nitr
ic oxide-mediated mechanism, it actually increases blood pressure (not de
sirable but not dangerous in normal volunteers and actually desirable in ac
ute, severe cyanide poisoning as hypotension is a very common finding).&n
bsp; It has been shown to be efficacious in acute, severe cyanide poiso
ning.
The sodium thiosulfate portion of the CAK has sometimes been suggested to b
e used alone, but all available data suggest that hydroxocobalamin is pre
ferable for mono-therapy.
What some industrial facilities that produce or handle large amounts of cya
nides or cyanogenic compounds such as acetonitrile have done, under the s
upervision of the facility Medical Officer (physician), is to stock some
antidote kits in the facility infirmary, and to transport exposed workers
to the chosen medical facility with the kits in the ambulance. Thi
s requires prior coordination with the EMS service and the receiving emerge
ncy department/hospital and an education program for the EMS/ED/hospital st
aff BEFORE an exposure occurs.
One industrial facility, under the supervision of the facility Medical Of
ficer, developed a program of training first responders to utilize an oxy
gen-powered breathing device with a crushed perle of amyl nitrite placed in
to the folds of the face mask. In a small case series, this was q
uite effective for inhalation exposures.
I have an extensive bibliography on this subject and would be willing to sh
are it with D-CHAS members, but it is too lengthy to include on the lists
erve. I will also be attending the D-CHAS meeting in SF next week
, and could arrange to meet and discuss in person with anyone who's inter
ested. Cyanide poisoning has been a specialty of mine since the 198
0s.
Another excellent on-line information source is the non-profit organization
, the Cyanide Poisoning Treatment Coalition, at:
http://www.cyanidepoisoning.org
As always, especially for D-CHAS members, engineering, administrative
, and PPE preventive measures are and always should be preferrable
to medical treatment which remains "shutting the barn door after the horse
s have run away".
Alan
Alan H. Hall, M.D.
Medical Toxicologist
TCMTS, Inc.
Laramie, WY
Colorado School of Public Health
Denver, CO
ahalltoxic**At_Symbol_Here**msn.com
Cell phone: (307) 399-1564
Sandler and Karo (Organic Functional Group Preparations, 1968, p.455) suggest that ther e are likely legal problems with administering antidotes. Deichmann and Gerarde (Toxicology of Drugs and Chemicals, p.191 mention thiosulfat e as an antidote (or part of one). They also mention sodium tetrath ionate. I hope this is helpful.
< /FONT>
From: DCHAS-L Discussion List [mailto:DCHAS-L**At_Symbol_Here**LIST.UVM.EDU]
Sent: Wednesday, March 17, 2010
10:07 PM
To: DCHAS-L**At_Symbol_Here**LI
ST.UVM.EDU
Subject: Re:
[DCHAS-L] Laboratory medical oversight
Does anyone have an opin ion or experience with kits for people working with cyanides? My understand ing is that some people have had difficulty obtaining amyl nitrite (?) kits .
On Wed, Mar 17, 2010 at 7:46 AM, List Moderator <ecgrants**At_Symbol_Here**uvm.edu> wrote:
From: Andrew Gross <gross.drew**At_Symbol_Here**gmail.com>
Date: March 17, 2010 8:28:26 AM EDT
Subject: Re: [DCHAS-L] Laboratory med ical oversight
In the fire service, our trucks car ry medical kits for the rare
instance we may not have an ambulance supporting our efforts. Our
trucks are also checked daily for wor king equipment. When the
inspection is done, the person init ials a calandar. The daily checks
calls for the person checking to ackn owledge the medical kit. One day
I realized no one checks inside of th e kit. I opened it, replaced all
of the expired stuff (50%ish) and on the calendar I marked off the day
that the next item is to expire so so meone knows to actually open the
bag up and look.
If you haven't realized where I was g oing, you should assign people to
check you fume hoods daily or weekly. To be honest, your working with
stuff that requires atropine, you s hould do that anyway. Check the
flow, cleanliness, all the equipm ent inside works, the door seals etc.
On the calendar that the inspector wi ll have to initial, mark the day
that the drugs will have to be replac ed and not just looked at with a
smile and say...its there.
Andrew
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