Paul,
High dose Hydroxycobalamine is marketed as 'Cyanokit' by Orphan Europe. 2.5 grams per bottle. Usual adult dose 5 grams iv. Costs about £200, but you can stop buying the other cyanide antidotes. So a small overall increase in cost.
The problem with the more conventional cyanide antidotes is that they are either complex to use, or toxic if the patient has not got cyanide poisoning (its really hard to tell in the smoke inhalations). So conventional antidotes are OK for clear cyanide poisoning (ingestion of cyanide salts etc) but are hardly ever get used in smoke inhalation.
Evidence for effectiveness is actually stronger for hydroxycobalamine than it is for the conventional antidotes (although no good trials for any of them).
I like the simplicity of a single antidote that is effective against cyanide, but does not have bad effects if I give it to a patient who turns out not to have cyanide poisoning after all.
I have the 'drug evaluation' and 'case of need' that was prepared for our hospital therapeutics committee if anyone wants to save themselves some work (contact me off list).
Regards,
Tim.
(PS. You have to warn the ITU or ward staff that the patient's urine will be a flourescent red for a day or two - unless you want to watch them worry!)
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Paul Ransom
Sent: 13 October 2005 11:56
To: [log in to unmask]
Subject: Re: Smoke inhalation & lactate
How are you giving this, Tim, adn what dose ?
It would be good if an adequate hydroxycobalamin were available,
but the 1mg or so doses available in the UK as an im injection is by
no means adequate to counteract a symptomatic level of cyanide
intoxication. The French and other European countries can use much
larger doses iv, but only a few places in the UK ( NPIS London to
my knowledge ) have supplies of it. As I understand, toxicologists
differ as to the advisability of stocking it.
Paul Ransom
On 13 Oct 2005, at 11:07, Coats Tim - Professor of Emergency Medicine
wrote:
> For smoke inhalation I measure CO but not usually lactate, and give
> hydroxycobalamine to anyone with a depressed level of consciousness.
> Tim.
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]]On Behalf Of Rowley Cottingham
> Sent: 12 October 2005 22:29
> To: [log in to unmask]
> Subject: Re: Smoke inhalation & lactate
>
>
> CO yes, lactate no. Cyanide poisoning is a binary event and if you
> get to
> hospital breathing you will continue to do so. CO poisoning is an
> altogether
> more subtle affair, and needs to be assiduously sought.
>
> Best wishes
>
>
> Rowley.
>
>
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Scott, Charles
> Sent: 12 October 2005 11:30
> To: [log in to unmask]
> Subject: Smoke inhalation & lactate
>
>
> Does anyone routinely measure blood lactate levels in patients
> involved in
> fires where smoke inhalation may have happened in the absence of
> any signs
> to suggest Cyanide poisoning? Lactate is part of the investigation
> on the
> Toxbase site (" If lactate concentration > 10 mmol/L in absence of
> significant burns and after correct of hypotension consider the
> possibility
> of cyanide poisoning." sic) And do you always measure CO levels in
> everyone
> involved in a house fire?
>
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