Date: Thu, 18 Mar 2010 08:47:04 -0600
Reply-To: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
Sender: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
From: Alan Hall <ahalltoxic**At_Symbol_Here**MSN.COM>
Subject: Re: Laboratory medical oversight, re:cyanides
In-Reply-To: <7AE992F862DE405F87C531393BA65B1F**At_Symbol_Here**bruekbergterm1>

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:
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 H. Hall, M.D.
Medical Toxicologist
Laramie, WY
Colorado School of Public Health
Denver, CO
Cell phone:  (307) 399-1564


Date: Thu, 18 Mar 2010 07:23:44 -0400
From: bruekberg**At_Symbol_Here**CHM.URI.EDU
S ubject: Re: [DCHAS-L] Laboratory medical oversight, re:cyanides
To: DC HAS-L**At_Symbol_Here**LIST.UVM.EDU

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] On Behalf Of Jim Tung
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**> wrote:

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.








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