We had a case a few months ago at Janus General--very sad and very scary. The patient came in after a house fire. He had some burns, but not enough to be the cause of his arrest. Instead, it had to be the asphyxia and possible toxicology of the smoke inhalation. I wanted to get a better idea of ideal care for these patients; for that I needed a toxicologist.

Few tox folks are smarter than Lewis Nelson, MD of the NYC Poison Center.

Note: In this episode we don't deal with the thermal injury of smoke inhalation

Cyanide Toxicity

* Empiric administration of  Hydroxocobalamin 5 g rapid IV drip x 1

* Even better if this can be given at the scene as soon as the patient arrests or is profoundly hypotensive

* Messes with labs that use colorimetric probes (cooximetry, lactate, LFTs, etc.) Get blood for cooximetry before giving the med if at all possible

* Dr. Nelson doesn't recommend giving sodium thiosulfate in addition to the Hydroxocobalamin

* An IM version is in the pipeline--this will be easier for EMS/emergency use

Hydroxocobalamin

You'll need 200 ml of Saline

Carbon Monoxide

* Put the patient on 100% fiO2

* Not much to do beyond that until the patient stabilizes

* See LITFL for more on CO

Methemoglobinemia

* Caused by Hb oxidation from the heat of the fire

* Administer Methylene Blue 2 mg/kg x 1 IVP

* May be worthwhile to start a drip if patient has resistant hypotension, but this is an unproven therapy

Now on to the Podcast...