Supportive care
O2 100% NRB
IVF and vasopressors for hypotension
Bicarb for acidemia (enchances of effect of nitrite and thiosulfate)
Antidote
O2 100% NRB
IVF and vasopressors for hypotension
Bicarb for acidemia (enchances of effect of nitrite and thiosulfate)
1st line therapy
Give empirically if<unk>  poisoning is suspected
Directly binds<unk>  forming cyanocobalamin which is readily excreted in the urine
Give 70mg/kg IV over 15min (5g is standard adult dose); may repeat 5g once as needed
Also give 25% sodium thiosulfate 1.65ml/kg IV (12.5g max dose) over 10min; may repeat at half original dose if needed
May cause temporary reddish discoloration of skin, plasma, urine, mucous membranes
Interferes with colorimetric tests -- Pulse ox, Hemoglobin, Carboyxhemoglobin, methemeglobin, oxyhemoglobin, Serum Cr, AST/ALT, bilirubin, magnesium for 2-3 days
Composed of two drugs(2 nitrites and a thiosulfate). The nitrites convert the iron in hemoglobin from the ferrous to the ferric form, creating methemoglobinemia. The thiosulfate is a sulfate donor, which allows the enzyme rhodanese to convert the<unk>  to thiocyanate that can be renally excreted.
2nd line therapy - use if Cyanokit unavailable
Consider using only Na thiosulfate (no nitrites) in cases where concern for CO poisoning since nitrate administration will severely decrease oxygen carrying capacity
Nitrites: form metHb which binds<unk>  more avidly than cytochrome oxidase
Thiosulfate: donates its sulfur group to<unk>  to form thiocyanate (less toxic than CN)
Thiosulfate: donates its sulfur group to<unk>  to form thiocyanate (less toxic than CN)
Nitrites are relatively contraindicated in patients with concomitant CO toxicity
Induction of metHb further decreases O2 delivery
Avoid nitrites in presence of severe hypotension if diagnosis is unclear
Amyl nitrite
Inhaled by patient (only use if unavailable to obtain IV)
Hold under patient's nose for 30s of each minute, for 3 minutes
Sodium nitrite
10mg/kg IV over 5min (use instead of amyl nitrite if IV is available)
Lack of measurable MetHb levels after administration confirms CN presence
Monitor MetHb and keep level <30%
Pediatric dosing is based on Hemoblogin (see Peds dosing below)
25% Sodium thiosulfate
1.65ml/kg IV (12.5g max dose) over 10min
may repeat at 1/2 original dose if needed
Inhaled by patient (only use if unavailable to obtain IV)
Hold under patient's nose for 30s of each minute, for 3 minutes
10mg/kg IV over 5min (use instead of amyl nitrite if IV is available)
Lack of measurable MetHb levels after administration confirms CN presence
Monitor MetHb and keep level <30%
1.65ml/kg IV (12.5g max dose) over 10min
may repeat at 1/2 original dose if needed
Cyanide toxicity
Blister chemical agents 
Chlorate toxicity
Lewisite 
Sulfhemoglobinemia
Sulfur mustard 
Methemoglobinemia
Phosgene oxime 