Jan Trojanowski PGY-5 Emerg UWO

Jan TrojanowskiPGY-5 Emerg UWO

Goals and Objectives

Case presentationManagement principlesNew(ish) developmentsExpert recommendations

Case

Plastics factory fire22 y.o. female workerNo burns, no injuriesSoot in mouthGCS 3??? Seizure

Case cont’d

IV, intubated by EMS96/50, 36.7oC, HR = 45, RR = 26, 96%Skin = cherry redNurse says…

Smells like burnt

almonds in here!!

Case cont’d

Investigations pH 6.95pO2 70pCO2 60HCO3 4AG 26Lactate >10CO 29%

Doctor, do

something!!

Add it all up…

Plastics fireCOMA

?SeizureLactate >10

Smells like almonds=

CYANIDE

Cyanide

cyanide

Cyanide

Cyanide Antidote Kit(aka Lilly Kit)• Components?• Amyl nitrite pearls• Sodium nitrite• Sodium thiosulfate

Downsides?

Another silver bullet?

Hydroxocobalamin

Adult: 2.5g in 100cc NS x2

Cyanide

hydroxocobolamin

Cyanocobalamin

Hydroxocobalamin

Interferes with colorimetric tests (ie. HGB, Cr, glu, albumin, INR/PTT, CK, etc.) Hypertension

Hydroxocobalamin notes

Fire brigades in ParisPrehospital/EMS

Lilly kit (no longer made)Cyanide kit

Special access$400

HydroxocobalaminSpecial access$800

Ann Emerg Med. 2009 Sep;54(3):386-394

Cyanide OPCC stats

2009 (to date)52 519 calls8 presumed cyanide exposures (2 deaths)No clinical ability to measure CN levels

????