Tue, 6 Nov 2012|
Mike McEvoy reviews tips for mixing the cyanide antidote and administering it to a smoke-inhalation victim in the field.
[MUSIC] [NOISE] Welcome to Training Minutes. Today I'm gonna talk about how to setup and administer a Cyanokit. 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 as 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. Cyanokit. 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 an ALS setting toa patient, probably who's in cardiac arrest, in 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 set up the kit, and get it 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. 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 that syringe to. And we'll come back to the stop **** later. So inside of the syano kit. Are currently two bottles which are glass bottles that contain the cyanokit 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 ccs of [INAUDIBLE] and then gets administered to the patient over the course of seven and a half minutes. So you would give two bottles or a total of five grams of cyanokit to an adult patient over the course of 15 minutes. The mixing is a little bit tricky for an individual who is 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 gonna use the spike to connect the bag of [UNKNOWN] to the [UNKNOWN] kit bottle itself. So, we'll open a 100 cc bag of [UNKNOWN]. We'll pop the top off the vile and then we'll use the spike. To connect the diluent 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. 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 diluent 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 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 [UNKNOWN] into the bottle. We're gonna 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. Inside of the [UNKNOWN] kit 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. Notice that the bottle has on it a vent and a 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 the dark red color of the mixture. So we've run the medication through the tubing of the first bottle of the cyanokit. We have an inter [UNKNOWN] line in the patient. Many patients during resuscitation like this are going to end up with a 15 gauge inter [UNKNOWN] line. And that is why we need to stop **** for this set up. 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 intraosseous 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 [INAUDIBLE] line with a power flush of 10 ccs to clear some of the debris inside of the bone cavity. We'll take the stop **** that we carry with the cyano kit. 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 stop ****. To a 30cc syringe. You can use a 30cc, a 20cc, a 60cc, you just need a big syringe. So we're connecting that to the stopcock. We're now gonna connect the medication to one piece of the stopcock, and then we'll connect the other end. To the interosseous line, once we 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 are ready to attach the stopcock to the interosseous line. We'll remove the syringe that we had there. We'll connect stop **** to the interosseous 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. Hydroxocobalamin cyanokit and then turn. The stopcock towards the patient and push the medication through the intraosseous line into the patient. 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 tubbing now to spike the second. Bottle of Hydroxocobalamin. Very shortly the company that manufactures this will release a single-dose bottle which will have two and a half grams plus two and a half 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 100 mL of diluent in each 2.5 grams, for a total of two bags of diluent into the new container. But most of us who are carrying the Cyanokit now have the 2 gram, two-bottle, 2.5 gram, two-bottle doses of the medication in our trucks. That's a system that we use to deliver to a interosseous line regardless of if you have a peripheral line or interosseus line. The stopcock is a smart idea so that you can pull the 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 effect 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. They will also interfere with some calorimetric test. So if you draw labs on the patient, prior to adminstering any of these, so that they can run tests like glucose, BUN, creatine, some of those labs will be interfered with after the cyano kit is administered. You'll see some change in your readings for carboxyhemoglobin, if you use a pulsoximeter 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 patients will experience a return of spontaneous circulation if cyanide is what's killed that patient and kept the patient dead happens in some point in the first ten minutes after administration of the kit. In a study in Paris, France, the largest study done on administration of this antidote 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. For 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 Ciano Kit 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 hydroxycobalamine. 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. Cyanokid hydroxycobalamine. And this is 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 physician order. Again, your local protocols dictate. How this would be given to a patient. Clearly this is done in serious circumstances and oftentimes not in environments where have a lot of time to make medical control contact. Thanks for watching Training Minutes. I'm Mike McEvoy, the EMS Editor for Fire Engineering Magazine.