Chemical Agents of Opportunity for Terrorism: TICs & TIMs

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Chemical Agents of Opportunity for Terrorism Training Support Package Participant Guide Slide 33 Chemical Agents of Opportunity for Terrorism: TICs & TIMs Cyanide Antidote Kit (CAK) • 3-steps – Amyl nitrite – Sodium nitrite – Sodium thiosulfate • Converts cyanide to thiocyanate • One kit treats two people Module Four – Cyanide & Fumigants 33 The first and oldest antidote is the 3-step cyanide antidote kit, still referred to as the “Lilly kit”. The first step involves the inhalation of amyl nitrite in the nares of the victim to induce a methemoglobinemia. Step two involves intravenous administration of sodium nitrite another methemoglobin inducer. Methemoglobin can bind cyanide to form cyanomethemoglobin. The third and last step involves the intravenous administration of sodium thiosulfate which binds the cyanide from methemoglobin forming thiocyanate, a renally excretable substrate. Sodium thiosulfate has a somewhat delayed onset of action, which is why the methemoglobin inducers are used. One kit treats two adults, or one adult twice, but full prescribing information is written on the box inside cover. December 2008 Version 2.0 Page 220
Chemical Agents of Opportunity for Terrorism Training Support Package Participant Guide Slide 34 Chemical Agents of Opportunity for Terrorism: TICs & TIMs Cyanide: CAK CAK Dosing • Amyl nitrite - inhale if no IV access yet • Sodium nitrite (3% solution) – Adults 300 mg (10 ml) IV over 15-20 min – Peds Hgb based • Sodium thiosulfate (50 ml 25% solution) – Adults 12.5 g (50 ml) IV – Peds 1.65 ml/kg IV • May repeat if large cyanide exposure Module Four – Cyanide & Fumigants 34 Amyl nitrite is best used in the pre-hospital setting and should be administered by inhalation only. The application of amyl nitrite induces methemoglobinemia which begins the process of binding free cyanide. This process is continued in the hospital setting by the application of sodium nitrite in 3% solution. Adults should receive 300mg (10ml) IV infusion over the course of 15-20 minutes, while pediatric dosing should be determined based on hemoglobin values. The process of eliminating the bound cyanide is started by the application of sodium thiosulfate in 25% solution. Adults should receive 12.5g (50 ml) IV while pediatric dosing be 1.65 ml/kg IV. Thiosulfate converts cyanohemoglobin to thiocyanate which can then be renally excreted. December 2008 Version 2.0 Page 221
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Chemical Agents of Opportunity for Terrorism: TICs & TIMs

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