8/5/2023 0 Comments Cyanide antidoteExposure by any route may cause systemic effects.Īt temperatures below 78 ☏, hydrogen cyanide is a colorless or pale-blue liquid (hydrocyanic acid) at higher temperatures, it is a colorless gas. Substantial absorption can occur through intact skin if vapor concentration is high or with direct contact with solutions, especially at high ambient temperatures and relative humidity. Hydrogen cyanide is absorbed well by inhalation and can produce death within minutes.Hydrogen cyanide has a distinctive bitter almond odor, but some individuals cannot detect it and consequently, it may not provide adequate warning of hazardous concentrations.Hydrogen cyanide gas mixes well with air, and explosive mixtures are easily formed. It is very volatile, readily producing flammable and toxic concentrations at room temperature. Hydrogen cyanide is a colorless or pale-blue liquid at room temperature.Persons whose clothing or skin is contaminated with cyanide-containing solutions can secondarily contaminate response personnel by direct contact or through off-gassing vapor.Aqueous solutions are referred to as hydrocyanic acid and prussic acid. For the remaining authors there are no conflicts of interest.Medical Management Guidelines for Hydrogen Cyanide He also participated at a National Advisory Board. Professor Geldner received a honorarium from Merck Germany for giving lectures. Acknowledgements Conflicts of interestĪll authors received an honorarium from Merck Serono Company for taking part in an Advisory Board on cyanide poisoning. We definitely need more animal, and if possible human, data to confirm or rule out the possible synergistic action of sodium thiosulfate and hydroxocobalamin in cyanide toxicity. As clearly marked in the algorithm, sodium thiosulfate is considered as an adjuvant and a second-line antidote, and is administered after other treatments have been initiated. Given the theoretically synergistic action and given the experience in the treatment of the toxicity of cyanide salts (or other forms of longer-acting cyanide toxicity), we propose the addition of sodium thiosulfate if lactate levels remain elevated or if other signs of cyanide toxicity persist despite administering the maximum dose of 150 mg/kg hydroxocobalamin. There is no evidence for administering doses of hydroxocobalamin higher than 150 mg/kg. For this reason, we propose a dose of 70 mg/kg hydroxocobalamin, to be repeated if persistent signs of toxicity exist. This monotherapy of hydroxocobalamin should be effective for severe cyanide toxicity, provided it is administered in sufficiently high doses. In our guidelines, we focus on the fast-acting hydrogen cyanide and advocate the use of hydroxocobalamin as a first-line antidote. The limitations to this study are the duration of the study model (limited to 60 min after the start of cyanide infusion) and the hemodynamic parameters as end points, instead of long-term sequelae 1,2,4 1,2,4 1,2,4. 4 have shown that sodium thiosulfate added to hydroxocobalamin shows no benefit for cyanide-induced shock in a swine model. The only limitation is that sodium thiosulfate and hydroxocobalamin may not be mixed in the same vial because this induces the formation of inefficient thiosulfatocobalamin 3.Īlthough there may be a theoretically synergistic action of sodium thiosulfate and hydroxocobalamin in cyanide toxicity, there is no evidence to support this at the moment, either in human data, or in animal data. Hydroxocobalamin and sodium thiosulfate can be combined safely. Therefore, theoretically, there is a synergistic action of sodium thiosulfate and hydroxocobalamin 1,2 1,2. Sodium thiosulfate acts as a sulfur donor to detoxify cyanide to thiocyanate by the enzyme rhodanese, whereas hydroxocobalamin binds cyanide and forms the nontoxic cyanocobalamin, which is renally excreted. Its use as a single antidote for acute cyanide toxicity is no longer supported or indicated 1,2 1,2.īecause of its immediate diffusion into the different tissue compartments, intravenously administered hydroxocobalamin has a rapid onset of action. We wish to thank Bebarta for drawing our attention to the position of sodium thiosulfate in the treatment of cyanide toxicity and giving us the opportunity to clarify our statements.Īlthough sodium thiosulfate is considered an ineffective antidote for acute cyanide toxicity because of poor intracellular penetration, slow onset of effect, a short half-life, and limited distribution volume, it is often used in conjunction with other rapid-acting antidotes.
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