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Empiric Management of Cyanide Toxicity Associated with Smoke Inhalation

Published online by Cambridge University Press:  26 November 2011

Daniel J. O’Brien ,
Donald W. Walsh ,
Colleen M. Terriff  and
Alan H. Hall
Daniel J. O’Brien*
Affiliation:
Associate Professor of Emergency Medicine, Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, Kentucky USA
Donald W. Walsh
Affiliation:
International Emergency Medicine & Disaster Specialists, Chicago Fire Department Emergency Medical Services Division Chief (Retired), Chicago, Illinois USA
Colleen M. Terriff
Affiliation:
Clinical Associate Professor, Washington State University College of Pharmacy, Deaconess Medical Center, Spokane, Washington USA
Alan H. Hall
Affiliation:
President and Chief Medical Toxicologist, Toxicology Consulting and Medical Translating Services, Inc., Laramie, Wyoming; Clinical Assistant Professor, Colorado School of Public Health, Denver, Colorado USA
*
Correspondence: Daniel J. O’Brien, MD, FACEP Associate Professor of Emergency Medicine Department of Emergency Medicine530 South Jackson StreetLouisville, Kentucky 40202 USA E-mail: daniel.obrien@louisville.edu
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Abstract

Enclosed-space smoke inhalation is the fifth most common cause of all unintentional injury deaths in the United States. Increasingly, cyanide has been recognized as a significant toxicant in many cases of smoke inhalation. However, it cannot be emergently verified. Failure to recognize the possibility of cyanide toxicity may result in inadequate treatment. Findings suggestive cyanide toxicity include: (1) a history of an enclosed-space fire scene in which smoke inhalation was likely; (2) the presence of oropharyngeal soot or carbonaceous expectorations; (3) any alteration of the level of consciousness, and particularly, otherwise inexplicable hypotension (systolic blood pressure ≤90 mmHg in adults). Prehospital studies have demonstrated the feasibility and safety of empiric treatment with hydroxocobalamin for patients with suspected smoke inhalation cyanide toxicity. Although United States Food and Drug Administration (FDA)-approved since 2006, the lack of efficacy data has stymied the routine use of this potentially lifesaving antidote. Based on a literature review and on-site observation of the Paris Fire Brigade, emergency management protocols to guide empiric and early hydroxocobalamin administration in smoke inhalation victims with high-risk presentations are proposed.

Keywords

cyanide toxicityhydroxocobalaminprehospital management smoke inhalation
Type
Comprehensive Review
Information
Prehospital and Disaster Medicine , Volume 26 , Issue 5 , October 2011 , pp. 374 - 382
Copyright
Copyright O’Brien © World Association for Disaster and Emergency Medicine 2012

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