If needed, a second dose (half of the initial dose) may be administered.

Sodium thiosulfate should be given IV immediately following sodium nitrite administration at a dose of 12.5 g.

If needed, a second dose of up to half the previous dose may be given, as long as methemoglobin levels are kept below 35-40%. A single dose of sodium nitrite is typically enough to raise methemoglobin levels to 20% in an adult.

Once the IV line is in place, amyl nitrite should be discontinued and 10 mL of 3% sodium nitrite (300mg) should be infused IV at a rate of 2.5 - 5.0 mL/min (2-4 mins).

Reapply until sodium nitrite can be administered (IV must be in place). Amyl nitrite should be given in alternate intervals of 15 sec followed by 15 sec rest, using a new ampule every 3 minutes.

Break and ampule of amyl nitrite in a handkerchief and hold it in front of the patients mouth/nose.

1 Tourniquet & Instructions for Treatment.

12 Ampules Amyl Nitrite Inhalants (0.3 mL).

2 Vials Sodium Thiosulfate Injection (12.5 g in 50mL of water).

2 Ampules Sodium Nitrite Injection (300 mg in10mL of water).

It may also cause transient hypertension, which can be beneficial in patients with cyanide poisoning. 2 Hydroxocobalamin imparts a harmless and transient reddish colour to the skin and urine. 1 By combining with cyanide, hydroxocobalamin forms cyanocobalamin (vitamin B 12), restoring mitochondrial function. Hydroxocobalamin should be administered as soon as cyanide poisoning is suspected - ideally in the prehospital setting. The nitrites induce methemoglobinemia, which can worsen hypotension and reduce the oxygen content of the blood, an important consideration in patients with concomitant carbon monoxide poisoning. It is relatively safe and is better tolerated than the ingredients of the traditional cyanide antidote kit (amyl nitrite, sodium nitrite and sodium thiosulfate). Hydroxocobalamin has been approved recently as a therapy for cyanide poisoning. The diagnosis is clinical and characterized by altered mental status, cardiovascular instability and lactic acidosis. However, treatment should not be delayed.

Tests that can confirm a diagnosis of cyanide poisoning are rarely available. Cyanide poisoning often occurs in victims of smoke inhalation. Hydroxocobalamin has been approved recently as a therapy for cyanide poisoning.

Cyanide poisoning antidote kit