Treatment of cyanide poisoning: The cyanide antidote kit first uses a small inhaled dose of amyl nitrite followed by intravenous sodium nitrite. This converts a portion of the hemoglobin's iron from ferrous iron to ferric iron, converting the hemoglobin into methaemoglobin. Cyanide is more strongly drawn to methaemoglobin than to the cytochrome oxidase of the cells, effectively pulling the cyanide off the cells and onto the methaemoglobin. Once bound with the cyanide, the Methaemoglobin becomes cyanmethaemoglobin. The next part of the cyanide antidote kit is sodium thiosulfate, which is administered intravenously. The sodium thiosulfate and cyanmethaemoglobin become thiocyanate, releasing the hemoglobin, and the thiocyanate is excreted by the kidneys.

Initial Therapy

	1. Remove patient to non-contaminated area
	2. Call doctor immediately
	3. If patient has stopped breathing, administer artificial respiration until normal respiration started.
	4. Break a Durule of Amyl nitrite Inhalant in a handkerchief.
	5. Hold it in front of the patient's mouth for 15 sec., followed by a rest for 15 sec.. Then reapply.
	6. Wash off any cyanide present on the skin. Remove any clothing that is contaminated by cyanide.

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Action

Content

• 2 ampoules Sodium nitrite Injection USP 300 mg in 10 ml of sterile water for injection
  
  
• 1 vial of Sodium thiosulfate injection I.P., 25 gm in 50 ml of sterile water for injection
  
  
• 12 durules of Amyl nitrite Inhalant, 0.3 ml
  
  
• 1 sterile 10 ml plastic disposable syringe with 22 gauge needle
  
  
• 1 sterile 50 ml plastic disposable syringe with 22 gauge needle
  
  
• 1 stomach tube
  
  
• 1 non-sterile 50 ml syringe
  
  
• 1 set of instruction for the treatment of cyanide poisoning

Warning

Both Sodium nitrite and Amyl nitrite in excessive doses induce dangerous methaemoglobinaemia and can cause death. The amounts found in a single Cyanide Antidote Package are not excessive for an adult. The doses for children should be calculated and the dosage adjusted. If signs of excessive methaemoglobinaemia develop (i.e. Blue skin and mucous membranes, vomiting, shock and coma), 1% methylene blue solution should be given intravenously. A total dose of 1 to 2 mg/kg of body weight should be administered over a period of 5 to 10 minutes and should be repeated in an hour if necessary. In addition, oxygen inhalation and transfusion of whole fresh blood should be considered.

Specific Therapy:
To be used at the discretion of the doctor, or paramedic

• Initiate inhalation of Oxygen immediately while preparing for intravenous administration.
• Simultaneously with oxygen, administer Amyl nitrite Inhalant for 15 to 30 seconds every 2 or 3 minutes.
• Discontinue Amyl nitrite and then inject 300 mg (10 ml of a 3% solution) of Sodium nitrite intravenously at the rate of 2.5 to 5 ml/minute. The recommended dose of Sodium nitrite for children is 6 to 8 ml/square meter of body surface area (approximately 0.2 ml/kg of body weight) but is not to exceed 10 ml.
• Immediately thereafter, inject 12.5 g (25 ml or a 50% solution) of Sodium thiosulfate for adults. The dosage for children is 7 g./square meter of body surface area, but dosage should not exceed 12.5 g. The same needle and vein may be used.
• If the poison is taken by mouth, gastric lavage should be performed as soon as possible, but this should not delay the treatments outlined above. Lavage may be done concurrently by a third person, a physician or a nurse, if one is available. One should take quick action without waiting for positive diagnostic tests.

The patients should be watched closely for atleast 24 to 48 hours. If signs of poisoning reappear, injection of both Sodium nitrite and Sodium thiosulfate should be repeated, but each in one-half the original dose. Even if the patient seems perfectly well, the medication may be given for prophylactic purpose 2 hours after the first injection.