We had a case a few months ago at Janus General–very sad and very scary. The patient came in after a house fire. He had some burns, but not enough to be the cause of his arrest. Instead, it had to be the asphyxia and possible toxicology of the smoke inhalation. I wanted to get a better idea of ideal care for these patients; for that I needed a toxicologist.
Few tox folks are smarter than Lewis Nelson, MD of the NYC Poison Center.
Note: In this episode we don't deal with the thermal injury of smoke inhalation
Cyanide Toxicity
- Empiric administration of Hydroxocobalamin 5 g rapid IV drip x 1
- Even better if this can be given at the scene as soon as the patient arrests or is profoundly hypotensive
- Messes with labs that use colorimetric probes (cooximetry, lactate, LFTs, etc.) Get blood for cooximetry before giving the med if at all possible
- Dr. Nelson doesn't recommend giving sodium thiosulfate in addition to the Hydroxocobalamin
- An IM version is in the pipeline–this will be easier for EMS/emergency use
Carbon Monoxide
- Put the patient on 100% fiO2
- Not much to do beyond that until the patient stabilizes
- See LITFL for more on CO
Methemoglobinemia
- Caused by Hb oxidation from the heat of the fire
- Administer Methylene Blue 2 mg/kg x 1 IVP
- May be worthwhile to start a drip if patient has resistant hypotension, but this is an unproven therapy
Additional New Information
More on EMCrit
- EMCrit 221 – Critical Burns Part II with Dennis Djogovic – Airway, Lungs, Tubes and Stuff(Opens in a new browser tab)
- EMCrit 219 – Critical Burn Patients in the ED/ICU – Part I with Dennis Djogovic(Opens in a new browser tab)
Additional Resources
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Scott – Yes, you can give hydroxocobalamin (HCB), and it may save a life. Or may not – we just don’t know! The three clinical HCB studies out of France, as well as the abstract from Houston, were all case series, and so weren’t designed to prove any improvement in outcomes. None of them even had a historical control group, let alone randomization, so the best we can conclude from these studies is that giving HCB is feasible by EMS. (http://millhillavecommand.blogspot.com/2014/04/part-2-different-edit.html) Sure, there’s animal data suggesting that HCB can resuscitate cyanide-poisoned pigs. There is also evidence that epinephrine, along with… Read more »
I think you hit the nail on the head as far as improving cardiac arrest care regardless of etiology: you have to start with high performance CPR and a system which demonstrates competence in the fundamentals. This will get you almost all of your survival gains. Because of this, once you’ve ensured the fundamentals are covered it will be rare to find another silver bullet, because statistically it probably won’t have nearly the same effect as CPR. I doubt we’d ever be able to generate the numbers necessary to answer the question, “does HCB improve survival to discharge neurologically intact… Read more »
Chris, You basically said exactly what I was going to, saving me having to type it. Brooks–Great Posts, here is Dr. Nelson’s response: Thanks for asking. We are all entitled to our opinion and there are no right answers for many of the issues raised. I agree that CPR (etc) is important, etc, but you can do all the CPR you want in a cyanide poisoned person and it wont help until the mitochondria can function again. That said, HCO is not going to save a dead person, so you still need all of the standard, high quality resusciation measures.… Read more »
I had a case like this when I was a resident. I remember my boss, Dr Simon Mardel (one of the most interesting people in history; his life is like the film “Outbreak”, works for the WHO hunting Ebola and other nasties) walking into resus, looked at the burnt patient, ran out of resus and came back with HCB and poured it into her. She survived though it did turn her arm purple. True story…….
Thank you very much for the extremely interesting and informative interview! I recently had a case of smoke inhalation who ended up receiving HCB. Certain team members insisted on getting arterial and venous BGA to calculate the O2-gradient, a narrow one supposedly implicating CN-intoxication. Although an intuitive concept, does it have any diagnostic role, especially with concurrent CO-intoxication? Thanks!
Thank you very much for the extremely interesting and informative interview! I recently had a case of smoke inhalation who ended up receiving HCB. Certain team members insisted on getting arterial and venous BGA to calculate the O2-gradient, a narrow one supposedly implicating CN-intoxication. Although an intuitive concept, does it have any diagnostic role, especially with concurrent CO-intoxication? Thanks
There is a treatment; I’m not only a Paramedic for the past 15 years, but I used to work as a commercial Driver in the gulf of Mexico oilfield industry. I’ve had experience with treatment of CO poisoning. The CO binds with the hemoglobin and prevents gas exchange. If its available, a hyperbaric chamber that can deliver O2 during treatment can be used to send O2 directly into solution in the blood plasma, and allow oxygenation of the bodily tissues despite CO poisoning. this is done by compressing the patient to 60ft of depth seawater. and the patient breathing O2… Read more »
I had two of these cases this week. The only difference was ROSC occurred within the first minute or two of chest compressions. What is your thought of administering HCB post cardiac arrest ? Now a days almost every structure fire victim is going to suffer from some level of cyanide poisoning. Scott, Thanks for all the excellent education opportunities !
Lewis – Great to have this dialogue. I suspect we’re not too far apart in either practice style, or dogma. After all, many of the tox attendings in my residency were trained through your fellowship, and I still have my textbook from my own NYCPC rotation years ago! Let me flip this discussion 180. Frankly, if I were arguing in favor of more routine HCB administration, I would describe the introduction of fomepizole, and of digoxin-specific Fab fragments. Neither one of those drugs had a supporting RCT, or even a strong case-control trial. Indeed, the important studies showing their benefit… Read more »
This was a truly informative interview with one of the all-time greats. I have a background in EM and EMS, and actually helped craft the OOH protocol Dr. Nelson describes. I just want to remind the readers that we are forgetting one of HCB’s most important qualities — that it’s risks are greatly outweighed by its benefits. Yes it is pricey and can cause alteration in lab results, but we give medications and therapies routinely with a much worse risk/benefit profile. Another forgotten quality of HCB is the impact it may have on a first responder’s ability to survive an… Read more »
Disclaimer: this response only applies to the specific challenges when resuscitating a downed firefighter. My main concern in the resuscitation of a downed firefighter is that there are a few burdensome steps prior to even administering HCB. The turnout gear, bunker gear, PPE–whatever you want to call it–that a firefighter wears takes at least 2 minutes to doff in the best of conditions. In trials at my own department we’ve seen that it takes upwards of 5 minutes to remove the gear in folks who have not practiced. More typically firefighters collapse due to cardiovascular complications, but assuming it is… Read more »
Hussein Egal
Hey guys: Please for give me for interjecting a different topic than Hydroxocobalamin and smoke/heat inhalation injury. But I do have a burning question on a different important topic; SAH. In my ED shop, a small community hospital in rural Minnesota we do see a fair amounts of headaches like every body else. Last night I saw a middle-aged lady who woke up with a severe headache that reached a maximum intensity within minutes if not seconds of its onset. She denies any history of primary headaches or ever having a headache of this severity in her life. She tried… Read more »
uhmm. I listened the podcast yesterday. I am fan!. Do you think we could have make any difference if this patient was put into ECMO?. Maybe that could have give HCB a chance to work.
So this is how Jack died then…
This has been one of my all time favorite posts. Thank you for a great resource. I do have one question regarding the oxidation of Hb from heat. Dr. Lewis mentioned, and you list the following: “Methemoglobinemia Caused by Hb oxidation from the heat of the fire Administer Methylene Blue 2 mg/kg x 1 IVP May be worthwhile to start a drip if patient has resistant hypotension, but this is an unproven therapy” Besides this post, I am unable to find any references. Could you ask Dr Lewis if he can refer me to a source. I am working on… Read more »
great