Antidotes for Cyanide Poisoning
SAN ANTONIO MILITARY MEDICAL CENTER FORT SAM HOUSTON TX
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We read with interest the review and guideline by Anseeuw et al. 1 titled Cyanide poisoning by fire smoke inhalation an European expert consensus . The authors reviewed the current literature succinctly and identified gaps in knowledge. They also elegantly reviewed the diagnosis of cyanide poisoning, which can be difficult. We concur with several of the authors recommendations that had not been clearly stated in other guidelines. In particular, we agree that sodium thiosulphate does not readily penetrate cells and its effectiveness is limited, despite older reviews that have reported that it should be used alone for cyanide toxicity. In addition, we conducted a comparative trial of sodium thiosulphate and hydroxocobalamin 2. In this clinically relevant model of cyanide-induced hypotension, we showed that sodium thiosulphate is not effective alone and it had 100 mortality 2. We also agree that although hydroxocobalamin has adverse effects, in sum, it is simpler to use, has less severe effects, has beneficial vasopressor effects and thus may be the best drug to use for severe cyanide toxicity 3. Finally, we agree that hydroxocobalamin is effective in cyanide-induced cardiac arrest, and that additional doses may be needed, as evidenced in our study, which showed that hydroxocobalamin is as effective as intravenous epinephrine for cyanide-induced cardiac arrest 4. However, we disagree that sodium thiosulphate adds to the effectiveness of hydroxocobalamin. We especially disagree that it improves outcome for severe cyanide-induced toxicity. We compared hydroxocobalamin to hydroxocobalamin with sodium thiosulphate and did not find a difference on group comparisons of vital signs, cyanide levels, other laboratory values and mortality 2.
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