Cyanide toxicity - Revision history

Danbot: Add MedicationDose SMW entries for hydroxocobalamin, sodium nitrite, sodium thiosulfate; doses verified against standard toxicology references

2026-03-20T17:36:46Z

Add MedicationDose SMW entries for hydroxocobalamin, sodium nitrite, sodium thiosulfate; doses verified against standard toxicology references

← Revisión anterior		Revisión del 17:36 20 mar 2026
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	==Disposition==		==Disposition==
	*Admit all patients for observation		*Admit all patients for observation


			==Medication Dosing==
			===1st Line===
			*{{MedicationDose\|drug=Hydroxocobalamin\|dose=5 g (70 mg/kg)\|route=IV over 15 min\|context=1st line antidote (Cyanokit)\|indication=Cyanide toxicity\|population=Adult\|notes=May repeat x1; give empirically if CN poisoning suspected}}

			===2nd Line (Lilly Kit)===
			*{{MedicationDose\|drug=Sodium nitrite\|dose=300 mg (10 mg/kg)\|route=IV over 5 min\|context=Methemoglobin-forming agent\|indication=Cyanide toxicity\|population=Adult\|notes=2nd line; avoid if concurrent CO poisoning; keep MetHb <30%}}
			*{{MedicationDose\|drug=Sodium thiosulfate\|dose=12.5 g (1.65 mL/kg of 25%)\|route=IV over 10 min\|context=Sulfur donor for cyanide elimination\|indication=Cyanide toxicity\|population=Adult\|notes=May repeat at half dose}}

	==See Also==		==See Also==

Rossdonaldson1: /* Video */

2024-04-17T20:10:39Z

Video

← Revisión anterior		Revisión del 20:10 17 abr 2024
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	==References==		==References==
	<references/>		<references/>

	~~==Video==~~
	~~{{#widget:YouTube\|id=vsA6_c-cbe4}}~~

	[[Category:Toxicology]]		[[Category:Toxicology]]

Rossdonaldson1: /* Differential Diagnosis */

2021-09-25T11:07:42Z

Differential Diagnosis

← Revisión anterior		Revisión del 11:07 25 sep 2021
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	==Differential Diagnosis==		==Differential Diagnosis==
	{{Chemical weapon DDX}}		{{Chemical weapon DDX}}
			{{Toxic gas exposure DDX}}
	{{Burn DDX}}		{{Burn DDX}}

Elcatracho: /* Cyanide Antidote Package (Lilly kit) */

2020-12-22T21:33:54Z

Cyanide Antidote Package (Lilly kit)

← Revisión anterior		Revisión del 21:33 22 dic 2020
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	===Cyanide Antidote Package (Lilly kit)===		===Cyanide Antidote Package (Lilly kit)===
	Composed of two drugs(2 nitrites and a thiosulfate). The nitrites convert the iron in hemoglobin from the ferrous to the ferric form, creating methemoglobinemia. The thiosulfate is a sulfate donor, which allows the enzyme rhodanese to convert the cyanide to ~~a form~~ that can be renally excreted.		Composed of two drugs(2 nitrites and a thiosulfate). The nitrites convert the iron in hemoglobin from the ferrous to the ferric form, creating methemoglobinemia. The thiosulfate is a sulfate donor, which allows the enzyme rhodanese to convert the cyanide to thiocyanate that can be renally excreted.
	*2nd line therapy - use if Cyanokit unavailable<ref>Hall AH, Saiers J, Baud F. Which cyanide antidote?. Crit Rev Toxicol. 2009;39(7):541-52.</ref>		*2nd line therapy - use if Cyanokit unavailable<ref>Hall AH, Saiers J, Baud F. Which cyanide antidote?. Crit Rev Toxicol. 2009;39(7):541-52.</ref>
	*Consider using only Na thiosulfate (no nitrites) in cases where concern for CO poisoning since nitrate administration will severely decrease oxygen carrying capacity		*Consider using only Na thiosulfate (no nitrites) in cases where concern for CO poisoning since nitrate administration will severely decrease oxygen carrying capacity

Spenceemmett: /* Diagnosis */

2020-05-13T14:48:42Z

Diagnosis

← Revisión anterior		Revisión del 14:48 13 may 2020
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	*Severe unexplained metabolic acidosis (lactic)		*Severe unexplained metabolic acidosis (lactic)
	*PO2 of venous blood similar to arterial blood		*PO2 of venous blood similar to arterial blood
	*~~normal~~ SpO2		*Normal SpO2 (same as CO poisoning)
	*Cherry-red skin color is uncommon		*Cherry-red skin color is uncommon

ClaireLewis: /* Clinical Features */

2019-08-20T22:18:30Z

Clinical Features

← Revisión anterior		Revisión del 22:18 20 ago 2019
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	*Affected by dose, route, formulation and exposure pattern		*Affected by dose, route, formulation and exposure pattern
	**Inhaled toxins more rapid than ingested		**Inhaled toxins more rapid than ingested
	***Inhalation exposure may cause syncope and death after only a few breaths		***Inhalation exposure may cause [[syncope]] and death after only a few breaths
	*'''Early signs'''		*'''Early signs'''
	**CNS stimulation (Headache, anxiety, confusion)		**CNS stimulation ([[Headache]], anxiety, [[confusion]])
	**Tachycardia, palpitations and hypotension		**[[Tachycardia]], [[palpitations]] and [[hypotension]]
	**Tachypnea		**Tachypnea
	**Cherry-red color (rarely seen)		**Cherry-red color (rarely seen)
	*'''Late signs'''		*'''Late signs'''
	**Nausea, ~~Vomiting~~		**[[Nausea]], vomiting
	**Bradycardia, hypotension, arrhythmias, asystole		**[[Bradycardia]], hypotension, [[arrhythmias]], asystole
	**Coma, ~~Seizures~~ (rare), ~~Mydiriasis~~		**[[Coma]], [[seizures]] (rare), Mydriasis
	**Bradypnea and pulmonary edema (non-cardiogenic), apnea		**Bradypnea and [[pulmonary edema]] (non-cardiogenic), apnea
	**Renal ~~Failure~~		**[[Renal failure]]
	**Hepatic Necrosis		**Hepatic Necrosis
	**Cyanosis		**Cyanosis
	**Rhabdo, bright red venules seen on fundoscopy		**[[Rhabdo]], bright red venules seen on fundoscopy

	===Chronic===		===Chronic===
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	*Ataxic peripheral neuropathy		*Ataxic peripheral neuropathy
	*Konzo		*Konzo
	**~~Spactic~~ upper motor neuron paraparesis seen in chronic ingestion of inadequately cooked casava		**Spastic upper motor neuron paraparesis seen in chronic ingestion of inadequately cooked casava

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1: /* Evaluation */

2019-08-08T17:41:52Z

Evaluation

← Revisión anterior		Revisión del 17:41 8 ago 2019
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	*RBC or serum cyanide levels (unlikely to return in time to be clinically useful)		*RBC or serum cyanide levels (unlikely to return in time to be clinically useful)

	===~~Evaluation~~===		===Diagnosis===
	*Smell of bitter almonds (only 60-80% of population can detect this)		*Smell of bitter almonds (only 60-80% of population can detect this)
	*Severe unexplained metabolic acidosis (lactic)		*Severe unexplained metabolic acidosis (lactic)
	*PO2 of venous blood similar to arterial blood		*PO2 of venous blood similar to arterial blood
	*normal SpO2		*normal SpO2
	*Cherry-red skin color is uncommon		*Cherry-red skin color is uncommon

	==Management==		==Management==

Rossdonaldson1: /* Work-Up */

2019-06-25T16:57:51Z

Work-Up

← Revisión anterior		Revisión del 16:57 25 jun 2019
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	==Evaluation==		==Evaluation==
	===Work-Up===		===Work-Up===
	*Lactate (normal lactate highly suggests another diagnosis)		*[[Lactate]] (normal lactate highly suggests another diagnosis)
	**Serum lactate >8 mmol/L has 94% sensitivity		**Serum lactate >8 mmol/L has 94% sensitivity
	*[[VBG]] and [[ABG]] (narrowing of the venous-arterial PO2 gradient, causes venous hyperoxemia/increased redness -- as does [[CO poisoning]])		*[[VBG]] and [[ABG]] (narrowing of the venous-arterial PO2 gradient, causes venous hyperoxemia/increased redness -- as does [[CO poisoning]])
	*Co-oximetry		*Co-oximetry
	*Chemistry ([[anion gap ~~acidosi~~]]s)		*Chemistry ([[anion gap acidosis]])
	*RBC or serum cyanide levels (unlikely to return in time to be clinically useful)		*RBC or serum cyanide levels (unlikely to return in time to be clinically useful)

Rossdonaldson1: /* Work-Up */

2019-06-25T16:56:35Z

Work-Up

← Revisión anterior		Revisión del 16:56 25 jun 2019
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	*Lactate (normal lactate highly suggests another diagnosis)		*Lactate (normal lactate highly suggests another diagnosis)
	**Serum lactate >8 mmol/L has 94% sensitivity		**Serum lactate >8 mmol/L has 94% sensitivity
	*VBG and ABG (narrowing of the venous-arterial PO2 gradient, causes venous hyperoxemia/increased redness -- as does CO poisoning)		*[[VBG]] and [[ABG]] (narrowing of the venous-arterial PO2 gradient, causes venous hyperoxemia/increased redness -- as does [[CO poisoning]])
	*Co-oximetry		*Co-oximetry
	*Chemistry (anion gap ~~acidosis~~)		*Chemistry ([[anion gap acidosi]]s)
	*RBC or ~~Serum~~ cyanide levels (unlikely to return in time to be clinically useful)		*RBC or serum cyanide levels (unlikely to return in time to be clinically useful)

	===Evaluation===		===Evaluation===

Rossdonaldson1: /* Work-Up */

2019-06-25T16:56:04Z

Work-Up

← Revisión anterior		Revisión del 16:56 25 jun 2019
Línea 47:		Línea 47:
	===Work-Up===		===Work-Up===
	*Lactate (normal lactate highly suggests another diagnosis)		*Lactate (normal lactate highly suggests another diagnosis)
	**Serum lactate > ~~> 8mmol~~/L has 94% sensitivity		**Serum lactate >8 mmol/L has 94% sensitivity
	*VBG and ABG (narrowing of the venous-arterial PO2 gradient, causes venous hyperoxemia/increased redness -- as does CO poisoning)		*VBG and ABG (narrowing of the venous-arterial PO2 gradient, causes venous hyperoxemia/increased redness -- as does CO poisoning)
	*Co-oximetry		*Co-oximetry