CO / Cyanide / Smoke-Inhalation Antidotes
CO / Cyanide / Smoke-Inhalation Antidotes - a deterministic tool in Sophie Well's EMS & Field Medicine group.
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What this is
Walk through the antidote decisions for the three smoke-inhalation toxidromes that share a structure fire scene: carbon monoxide (100% non-rebreather, hyperbaric-oxygen criteria - syncope, neurological deficit, COHb >25% non-pregnant or >15% pregnant, persistent symptoms after normobaric O2), cyanide (hydroxocobalamin 5 g IV - 70 mg/kg pediatric - over 15 minutes, or sodium thiosulfate 12.5 g IV as an adjunct or substitute; avoid the nitrite components of the older kit in concurrent CO exposure because methemoglobinemia compounds tissue hypoxia), and the supportive care for the inhalational airway burn and pulmonary insult that often accompany both.
When to use it
Use this at the bedside or in the rig when a closed-space fire victim is symptomatic with altered mental status, acidosis, or hemodynamic instability disproportionate to the burn TBSA, when cyanide is suspected from soot, lactate >8 mmol/L, or persistent shock after fluid resuscitation, and when a clinician needs to remember why the old Lilly nitrite-thiosulfate kit is no longer first-line in fire-scene cyanide. Confirm the toxidrome clinically - cyanide assays do not return in time to drive bedside decisions.
References
FDA labeling: Cyanokit (hydroxocobalamin) and Nithiodote (sodium nitrite + sodium thiosulfate). UHMS guidance for HBO indications.
Sophie Well is a reference and educational tool. Not medical, legal, or financial advice. Does not replace clinician judgment, professional billing review, or legal counsel.