Tue, 6 Nov 2012|
Mike McEvoy reviews tips for mixing the cyanide antidote and administering it to a smoke-inhalation victim in the field.
[BLANK_AUDIO] Welcome to Training Minutes. Today I'm going to talk about how to setup and administer a cyano kit. A cyanide antidote kit used by firefighters and EMS providers who treat victims pulled from a structure fire with smoke inhalation who are in extremis or was we would say. Serious condition. People who have suffered the effects of smoke inhalation probably are poisoned, not only with carbon monoxide but with cyanide as you've seen in the fire engineering literature, in the fire magazines, and in the medical literature for the last several years. Cyano kit. Is an antidote that's a precursor to vitamin B12, the only antidote that's safe to administer to a patient who has smoke inhalation and cyanide poisoning as a consequence of smoke inhalation. While there are other antidotes on the market, none of those are appropriate to give to the smoke inhalation victim. So you're gonna end up giving this kit in a ALS setting to a patient probably who's in cardiac arrest. And not the best of circumstances to have to work. So I thought today I would go through how to mix the drugs together. How to setup the kit and get ready for administration. When seconds count, which is the situation that you're going to find yourself in giving this kit. So the kit itself is not enough to have the supplies that you need to administer it. In addition to the kit, which contains the medication and the mixing spikes, you'll also need two bags, 100 cc bags or 100 mL bags of normal saline. You'll need a syringe in order to pull some of the medication from the vial, and administer it into the port that you have connected to an intravenous line in the patient. And more than likely a stop **** to connect the syringe, too, and we'll come back to the stop **** later. So inside of the cyanno kit. Are currently two bottles, which are glass bottles that contain the cyano kit actual powder that need to be mixed with the [INAUDIBLE]. The 100 cc bags of normal saline that we had looked at earlier. Each bottle. Mixes with 100 cc's diluent and then gets administered to the patient over the course of seven and a half minutes. So you would give two bottles or total of five grams of sionkit to an adult patient over the course of 15 minutes. But mixing is a little bit tricky for an individual who's not used to mixing medications in the field which is most of us in the EMS environment. The kit comes with a spike, and we're going to use the spike the bag of diluent to the cyanokit bottle itself. So we'll open a 100 cc bag of diluent, we'll pop the top off the vial, and then we'll use the spike. They connect the [UNKNOWN], to the bottle itself. The spike is basically, a, medication mixing spike. Which contains, a sharp end, on both sides of the spike. To allow the medication to come from the bag, into the bottle. So we'll spike the bag. [SOUND] Then we'll spike the bottle, similar to how we would spike with an IV solution. Put the bag back upwards, squeeze the 100 ccs of [UNKNOWN] into the bottle, and you'll probably have to release it. Once or twice in order to get the air out of the bottle itself and you'll notice that the mixture that's coming back into the bag is reddish colored. The powder inside the bottle is actually red and one of the side effects of the medication when we give it to a patient is to turn their skin red, to turn their urine red, to turn most of the patient red. Which lasts for five to seven days after the medication is administered. So now we have all of the Diluent into the bottle, we're going to pull the spike out of the bottle, and we're ready now to mix the medication inside of the bottle. To mix it, you need to be cautious because it tends to bubble if you were to shake the bottle. So instead, we'll invert the bottle several times and continue to invert the bottle back and forth for about 30 seconds to completely mix up the medication. Later on, we'll take the bottle out of the box and take a look at what the bottle actually looks like. The next thing that we need to do is to attach the intravenous set. [SOUND] Inside of the Cyanokit is a drip set that can be used with the bottle. We'll open up the drip set, and we'll spike the bottle, just as we would any IV solution. [BLANK_AUDIO] Notice that the bottle has on it a vent and the vent actually allows air to move into the bottle so that fluid will flow. We'll spike the tubing with the solution. We'll hang it on an IV pole. And we'll run, the solution through the tubing to get it ready to administer to the patient. Notice a dark red color, of the mixture. So we've run the, medication through the tubing of the first, bottle of the cyano kit. We have an inter-osseous line in the patient. Many patients during resuscitations like this are going to end up with a 15-gauge inter-osseous line. And that is the reason why we need a stop-cock for this setup. In order to get this medication to run,. Into the patient in seven and a half minutes, we're gonna have to syringe some of the medication in ourselves, manually. So, if we were to connect this bottle, to the interoscious line, we would not be able to squeeze the bottle to get the medication to move into the patient any faster because it's a glass bottle. So we've already flushed the interosseous line with a power flush of 10 cc to clear some of the debris inside of the bone cavity. We'll take the stopcock that we carry with the Cyanokit and we've added that to the supplies that we carry. That's not something that comes with the kit itself. And we'll connect the stopcock. To a 30 cc syringe. You can use a 30 cc, a 20 cc, a 60 cc, you just need a big syringe. So we're connecting to that the stop ****. We're now gonna connect the medication to one piece of the stop ****. And then we'll connect the other end. To the interosseous line once we've pulled some of the medication into the syringe. So we'll pull some of the medication into the syringe, load it up. So now we have the medication to the tip of the stopcock. We're ready to attach the stopcock to the interosseous line. We'll remove the syringe that we had there. We'll connect stopcock to the intraosseous line and we're now in a position, with it connected, to be able to pull medication into the syringe from the bottle of medication that we have hanging, hydroxycobalamin, cyanokit, and then turn. The stop caulk towards the patient and push the medication through the interosseous line. And you can continually turn back, pull medication from the bottle, turn back to the patient, push medication into the patient. And deliver it over seven and a half minutes using the same tubing now to spike the second. Bottle of hydroxocobalamin. Very shortly the company that manufactures this will release a single-dose bottle which will have 2.5 grams plus 2.5 grams for a total of five grams in one single bottle. So it won't be necessary to actually spike two bottles. You will still need to use a hundred mls of [UNKNOWN] in each two and a half grams for a total of two bags of [UNKNOWN] into the new container. But most of us who are carrying the Ciano kit now have the 2 gram, 2 bottle, 2 and a half gram, 2 bottle doses of the medication in our trucks. That's the system that we use to deliver it through an interosseous line regardless of whether you have peripheral line or an interosseous line, the stop **** is a smart idea so that, you can pull a medication out of the bottle if it's not flowing as quickly as you need it to flow. As I mentioned previously, some of the side effects you'd expect to see from this in your patient are turning the color of the skin red which will happen very shortly after you administer the first bottle. Urine will turn red immediately. All of those things will stay red on the patient for about five to seven days. It will also interfere with some calio-metric test, so if you draw labs on the patient, prior to administering any of these, so they can run tests like glucose, B.U.N. creatinine, some of those labs will be interfered with after the sciano-kit is administered. You'll see some change in your readings for carboxyhemoglobin if you use a pulse oximeter that's able to measure that. Those from the red coloring of the blood will actually be interfered with for about five to ten minutes after the initial dose of medication is given to the patient. And if you're doing CPR on the patient, which is going to be the case with many of these individuals who get this antidote. You'll find that the patient's will experience return of spontaneous circulation if cyanide is what has killed that patient and kept the patient dead. Happens at some point in the first ten minutes after administration of the kit. In the study in Paris, France, the largest study done on administration of this and hydroxocobalamin, brand name Cyanokit. About 50% of patients who were in cardiac arrest following a structure fire. That were grabbed out of a fire. Had reversal of cardiac arrest with return of vital signs on scene. From administering this antidote. Currently in the United States without this antidote, our efficiency at rescuing those patients and seeing them return to life is less than 1%. So to go from less than 1% to over 50% means that giving a cyanide antidote is critical. The only cyanide antidote that's safe to give to a smoke inhalation patient. Is the Cyanokit, because it doesn't interfere with oxygen-carrying capacity like every other cyanide antidote that's on the market. Let me take apart the box that's holding the bottle just so that you can see the actual medication. Inside of this cardboard box is a glass bottle. [SOUND] The glass bottle actually holds the hydroxocobalamin. And you can see the red color of the medication, the dark red color. The glass bottle is labeled with the name of the medication, Cyanokit Hydroxocobalamin. And this is a 2 and a half gram bottle. So again, for an adult. Two bottles of this, for a total of five grams, is the normal dose. For a child, there's pediatric dosing that you would follow based on your local protocols. Some systems give this on standing orders, some of them require a physician order. Again your local protocols dictate. How this would be given to a patient. Clearly, this is done in serious circumstances, and often times not in environments where you have a lot of time to make medical control contact. Thanks for watching training minutes, I'm Mike McEvoy the EMS editor for Engineering Magazine.