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Rx Spotlight: Hydroxycobalamin


As you likely know by now the CYANOKIT is to be administered without delay if you suspect cyanide poisoning. Support of the patients' airway, breathing, and circulation are always the priority and infusion of the kit should always come after those immediate life threats are treated. The kit compliments your efforts only if you include immediate attention to airway patency, adequacy of oxygenation as well as hydration and cardiovascular support.

Cyanide is an extremely toxic poison. In the absence of rapid and adequate treatment, exposure to a high dose of cyanide can result in death within minutes due to the inhibition of cytochrome oxidase resulting in arrest of cellular respiration. A fancy way to say CELLULAR HYPOXIA. The kit simply binds cyanide ions and chemically alters it to form cyanocobalamin which can safely be excreted from the urine.

As a brief segway and pertinent reminder - know that Poison control centers are also a good resource when it comes to suspected poisonings of any time. They can be reached 24/7 by calling 1-800-222-1222. Consider putting this contact into your personal phone, or the phone in the ambulance if that is applicable to your agency.

Cyanide poisoning may result from a variety of causes, but of utmost concern to us in the fire service is closed space fires. This B12 vitamin derivative serves as the antidote. Not only could it save victims trapped in a fire, but it could also potentially save your fellow first responder on the fireground. Signs and symptoms may also vary and can include the following:

The starting dose for adults is 5 g (the entire vial) infused over a 15-minute period. Depending on the severity a second dose could certainly be warranted. From the image below you can ascertain that the kit does NOT come ready to use. It will have to be reconstituted with 200 ml of diluent (NSS is preferred) - this is also not included -- it comes separately. If saline is not readily available, you can use LR or D5W. After the diluent is added, it should be a deep red color and free from particulate matter.

This safety profile of hydroxycobalamin is well known. Adverse reactions are fairly rare, the most common reactions include chromaturia (deep red urine) and erythema. These issues seem to be dose dependent and were present in all groups who received > 5 grams. The chromaturia has been documented in some instances to last up to 35 days post infusion.

These kits can be relatively expensive, however in closing did you know that CYANOKIT is a registered trademark of SERB pharmaceuticals? They have a promise to all first responder agencies:

If the kit is given in the line of duty to police, fire, or EMS -- SERB will replace it at no charge. You simply have to contact SERB at 1-844-293-0007 or email fill out a request form and include your physician medical director licensure within 6 months of the administration.

July 8, 2024

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC

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