Jan Trojanowski PGY-5 Emerg UWO

Some quick toxicology

Jan TrojanowskiPGY-5 Emerg UWO

Goals and ObjectivesCase presentationManagement principlesNew(ish) developmentsExpert recommendationsCasePlastics factory fire22 y.o. female workerNo burns, no injuriesSoot in mouthGCS 3??? Seizure

Case contdIV, intubated by EMS96/50, 36.7oC, HR = 45, RR = 26, 96%Skin = cherry redNurse says

Smells like burnt almonds in here!!Case contdInvestigations pH 6.95pO2 70pCO2 60HCO3 4AG 26Lactate >10CO 29%

Doctor, do something!!Add it all upPlastics fireCOMA?SeizureLactate >10Smells like almonds=CYANIDECyanide

cyanide

CyanideCyanide Antidote Kit(aka Lilly Kit)Components?Amyl nitrite pearlsSodium nitriteSodium thiosulfate

Downsides?

Another silver bullet?Hydroxocobalamin

Adult: 2.5g in 100cc NS x2

Cyanide

hydroxocobolamin

Cyanocobalamin

HydroxocobalaminInterferes with colorimetric tests (ie. HGB, Cr, glu, albumin, INR/PTT, CK, etc.) Hypertension

Hydroxocobalamin notesFire brigades in ParisPrehospital/EMS Lilly kit (no longer made)Cyanide kitSpecial access$400 HydroxocobalaminSpecial access$800

Ann Emerg Med. 2009 Sep;54(3):386-394

Cyanide OPCC stats2009 (to date)52 519 calls8 presumed cyanide exposures (2 deaths)No clinical ability to measure CN levels

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