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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Pohl H, Mumtaz M. Evaluation of interactions in chemical mixtures containing cyanides. Regul Toxicol Pharmacol 2022; 132:105187. [DOI: 10.1016/j.yrtph.2022.105187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
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H2S in Critical Illness—A New Horizon for Sodium Thiosulfate? Biomolecules 2022; 12:biom12040543. [PMID: 35454132 PMCID: PMC9029606 DOI: 10.3390/biom12040543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 12/13/2022] Open
Abstract
Ever since the discovery of endogenous H2S and the identification of its cytoprotective properties, efforts have been made to develop strategies to use H2S as a therapeutic agent. The ability of H2S to regulate vascular tone, inflammation, oxidative stress, and apoptosis might be particularly useful in the therapeutic management of critical illness. However, neither the inhalation of gaseous H2S, nor the administration of inorganic H2S-releasing salts or slow-releasing H2S-donors are feasible for clinical use. Na2S2O3 is a clinically approved compound with a good safety profile and is able to release H2S, in particular under hypoxic conditions. Pre-clinical studies show promise for Na2S2O3 in the acute management of critical illness. A current clinical trial is investigating the therapeutic potential for Na2S2O3 in myocardial infarct. Pre-eclampsia and COVID-19 pneumonia might be relevant targets for future clinical trials.
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de Koning MSLY, van Dorp P, Assa S, Hartman MHT, Voskuil M, Anthonio RL, Veen D, Pundziute-Do Prado G, Leiner T, van Goor H, van der Meer P, van Veldhuisen DJ, Nijveldt R, Lipsic E, van der Harst P. Rationale and Design of the Groningen Intervention Study for the Preservation of Cardiac Function with Sodium Thiosulfate after St-segment Elevation Myocardial Infarction (GIPS-IV) trial. Am Heart J 2022; 243:167-176. [PMID: 34534493 DOI: 10.1016/j.ahj.2021.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/18/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Ischemia and subsequent reperfusion cause myocardial injury in patients presenting with ST-segment elevation myocardial infarction (STEMI). Hydrogen sulfide (H2S) reduces "ischemia-reperfusion injury" in various experimental animal models, but has not been evaluated in humans. This trial will examine the efficacy and safety of the H2S-donor sodium thiosulfate (STS) in patients presenting with a STEMI. STUDY DESIGN The Groningen Intervention study for the Preservation of cardiac function with STS after STEMI (GIPS-IV) trial (NCT02899364) is a double-blind, randomized, placebo-controlled, multicenter trial, which will enroll 380 patients with a first STEMI. Patients receive STS 12.5 grams intravenously or matching placebo in addition to standard care immediately at arrival at the catheterization laboratory after providing consent. A second dose is administered 6 hours later at the coronary care unit. The primary endpoint is myocardial infarct size as quantified by cardiac magnetic resonance imaging 4 months after randomization. Secondary endpoints include the effect of STS on peak CK-MB during admission and left ventricular ejection fraction and NT-proBNP levels at 4 months follow-up. Patients will be followed-up for 2 years to assess clinical endpoints. CONCLUSIONS The GIPS-IV trial is the first study to determine the effect of a H2S-donor on myocardial infarct size in patients presenting with STEMI.
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RETRACTED: Proof of concept efficacy study of intranasal stabilized isoamyl nitrite (SIAN) in rhesus monkeys against acute cyanide poisoning. Regul Toxicol Pharmacol 2021; 123:104927. [PMID: 33852946 DOI: 10.1016/j.yrtph.2021.104927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 11/20/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editors-in-Chief as the authors were unable to provide documentation of approval for the interinstitutional assurance /vertebrate animal section of the paper by the relevant authority, Public Health Service (PHS) Office of Laboratory Animal Welfare (OLAW) in the time that was provided.
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Efficacy of oral administration of sodium thiosulfate in a large, swine model of oral cyanide toxicity. J Med Toxicol 2021; 17:257-264. [PMID: 33821433 DOI: 10.1007/s13181-021-00836-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/04/2021] [Accepted: 02/25/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Cyanide is a deadly poison, particularly with oral exposure where larger doses can occur before symptoms develop. Prior studies and multiple governmentagencies highlight oral cyanide as an agent with the potential for use in a terrorist attack. Currently, there are no FDA approved antidotes specific to oralcyanide. An oral countermeasure that can neutralize and prevent absorption of cyanide from the GI tract after oral exposure is needed. Our objective was toevaluate the efficacy of oral sodium thiosulfate on survival and clinical outcomes in a large, swine model of severe cyanide toxicity. METHODS Swine (45-55kg) were instrumented, sedated, and stabilized. Potassium cyanide (8 mg/kg KCN) in saline was delivered as a one-time bolus via an orogastric tube. Three minutes after cyanide, animals randomized to the treatment group received sodium thiosulfate (510 mg/kg, 3.25 M solution) via orogastric tube. Our primary outcome was survival at 60 minutes after exposure. We compared survival between groups by log-rank, Mantel-Cox analysis and trended labs and vital signs. RESULTS At baseline and time of treatment all animals had similar weights, vital signs, and laboratory values. Survival at 60 min was 100% in treated animals compared to 0% in the control group (p=0.0027). Animals in the control group became apneic and subsequently died by 35.0 min (20.2,48.5) after cyanide exposure. Mean arterial pressure was significantly higher in the treatment group compared to controls (p=0.008). Blood lactate (p=0.02) and oxygen saturation (p=0.02) were also significantly different between treatment and control groups at study end. CONCLUSION Oral administration of sodium thiosulfate improved survival, blood pressure, respirations, and blood lactate concentrations in a large animal model of acute oral cyanide toxicity.
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Safety and Tolerability of Sodium Thiosulfate in Patients with an Acute Coronary Syndrome Undergoing Coronary Angiography: A Dose-Escalation Safety Pilot Study (SAFE-ACS). J Interv Cardiol 2020; 2020:6014915. [PMID: 33041696 PMCID: PMC7532357 DOI: 10.1155/2020/6014915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
Background In animal studies, hydrogen sulfide (H2S) has been shown to protect the heart from ischemia-reperfusion injury. This study evaluates the safety and tolerability of the H2S donor sodium thiosulfate (STS) in patients with acute coronary syndrome (ACS). Methods Eighteen patients, undergoing coronary angiography for ACS, received STS intravenously immediately after arrival at the catheterization laboratory according to a “3 + 3 dose-escalation design” with fixed dosing endpoint (0, 2.5, 5, 10, 12.5, and 15 grams). This first dose STS was combined with verapamil and nitroglycerin required for transradial procedures. A second dose STS was administered 6 hours later. Primary endpoint was dose-limiting toxicity, defined as significant hemodynamic instability or death up to 24 hours or before discharge from the coronary care unit. Secondary outcomes included the occurrence of anaphylaxis, nausea, vomiting, and systolic blood pressure (SBP) course. Results Sixteen patients received two dosages of STS and two patients one dosage. None of the patients reached the primary endpoint, nor experienced a serious adverse event. We observed a clinically well-tolerated decline in SBP 1 hour after administration of the first STS dose and concomitant verapamil/nitroglycerin. SBP for all patients together reduced 16.8 (8.1–25.5) mmHg (P = 0.0008). No significant decline in SBP occurred after the second dose. Mild nausea was observed in one patient. Conclusion This is the first report on sodium thiosulfate administration in patients with acute coronary syndromes. Our data suggest that sodium thiosulfate was well tolerated in this setting. The potential benefit of this intervention has to be examined in larger studies.
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Case Report of Lethal Toxin Lurking in an Edible Plant. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY 2019; 26:e14-e18. [PMID: 31904202 DOI: 10.15586/jptcp.v26i3.633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/20/2019] [Indexed: 11/18/2022]
Abstract
Cyanide is notoriously known to the public for more than a century now as a weapon of mass destruction (Zyklon B gas - hydrogen cyanide used by Nazis), an agent for chemical warfare during World War I (hydrogen cyanide) and very infamous "Suicide Pill" used in the past by military and espionage organizations during World War II (potassium cyanide). During the modern industrial era, cyanide poisoning is commonly associated with the industrial exposure and domestic fires. But there is little awareness about potentially fatal consequences of cyanide poisoning from common food sources. Here, we present the case report of a 79-year-old female with acute cyanide poisoning from improperly prepared cassava leaves. Symptoms from ingested toxin may start a few hours after exposure, which include headache, confusion, ataxia, seizures, palpitations, nausea, vomiting, abdominal pain, flushing, and itching of the skin. Patients may develop hypotension, cardiac arrhythmias, renal failure, hepatic necrosis, rhabdomyolysis, and metabolic acidosis; a multisystem manifestation of hypoxia at the cellular level. Multiple treatment strategies are available to treat cyanide poisoning, including sodium nitrite, sodium thiosulfate, and hydroxycobalamine. This is one of the scenarios where a thorough history, awareness of agents causing cyanide toxicity and knowledge of clinical manifestations can help avoid delays in prompt decision-making for appropriate treatment, thus reducing morbidity, mortality, and prolonged hospital course.
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Inhalationstrauma durch Rauchgas bei Bränden. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0450-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Petrikovics I, Kiss L, Chou CE, Ebrahimpour A, Kovács K, Kiss M, Logue B, Chan A, Manage ABW, Budai M, Boss GR, Rockwood GA. Antidotal efficacies of the cyanide antidote candidate dimethyl trisulfide alone and in combination with cobinamide derivatives. Toxicol Mech Methods 2019; 29:438-444. [DOI: 10.1080/15376516.2019.1585504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Ilona Petrikovics
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Lóránd Kiss
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Ching-En Chou
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Afshin Ebrahimpour
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Kristóf Kovács
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Márton Kiss
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Brian Logue
- Department of Chemistry and Biochemistry, South Dakota State University, Brookings, SD, USA
| | - Adriano Chan
- Department of Medicine, University of California, San Diego, CA, USA
| | - Ananda B. W. Manage
- Department of Mathematics and Statistics, Sam Houston State University, Huntsville, TX, USA
| | - Marianna Budai
- Department of Chemistry, Sam Houston State University, Huntsville, TX, USA
| | - Gerry R. Boss
- Department of Medicine, University of California, San Diego, CA, USA
| | - Gary A. Rockwood
- US Army Medical Research Institute of Chemical Defense, APG, MD, USA
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Ahammad AS, Pal PR, Shah SS, Islam T, Mahedi Hasan M, Qasem MAA, Odhikari N, Sarker S, Kim DM, Abdul Aziz M. Activated jute carbon paste screen-printed FTO electrodes for nonenzymatic amperometric determination of nitrite. J Electroanal Chem (Lausanne) 2019. [DOI: 10.1016/j.jelechem.2018.11.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Identification of specific metabolic pathways as druggable targets regulating the sensitivity to cyanide poisoning. PLoS One 2018; 13:e0193889. [PMID: 29879736 PMCID: PMC5991913 DOI: 10.1371/journal.pone.0193889] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/20/2018] [Indexed: 11/19/2022] Open
Abstract
Cyanide is a potent toxic agent, and the few available antidotes are not amenable to rapid deployment in mass exposures. As a result, there are ongoing efforts to exploit different animal models to identify novel countermeasures. We have created a pipeline that combines high-throughput screening in zebrafish with subsequent validation in two mammalian small animal models as well as a porcine large animal model. We found that zebrafish embryos in the first 3 days post fertilization (dpf) are highly resistant to cyanide, becoming progressively more sensitive thereafter. Unbiased analysis of gene expression in response to several hours of ultimately lethal doses of cyanide in both 1 and 7 dpf zebrafish revealed modest changes in iron-related proteins associated with the age-dependent cyanide resistance. Metabolomics measurements demonstrated significant age-dependent differences in energy metabolism during cyanide exposure which prompted us to test modulators of the tricarboxylic acid cycle and related metabolic processes as potential antidotes. In cyanide-sensitive 7 dpf larvae, we identified several such compounds that offer significant protection against cyanide toxicity. Modulators of the pyruvate dehydrogenase complex, as well as the small molecule sodium glyoxylate, consistently protected against cyanide toxicity in 7 dpf zebrafish larvae. Together, our results indicate that the resistance of zebrafish embryos to cyanide toxicity during early development is related to an altered regulation of cellular metabolism, which we propose may be exploited as a potential target for the development of novel antidotes against cyanide poisoning.
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Haouzi P, Gueguinou M, Sonobe T, Judenherc-Haouzi A, Tubbs N, Trebak M, Cheung J, Bouillaud F. Revisiting the physiological effects of methylene blue as a treatment of cyanide intoxication. Clin Toxicol (Phila) 2018; 56:828-840. [PMID: 29451035 DOI: 10.1080/15563650.2018.1429615] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although methylene blue (MB) had long been proposed to counteract the effects of cyanide (CN) intoxication, research on its mechanisms of action and efficacy has been abandoned for decades. Recent studies on the benefits of MB in post-anoxic injuries have prompted us to reexamine the relevance of this historical observation. METHODS Our study was performed in adult male Sprague-Dawley rats and on HEK293T epithelial cells. First, the effects and toxicity of MB (0-80 mg/kg) on circulation and metabolism were established in four urethane-anesthetized rats. Then nine rats received a lethal infusion of a solution of KCN (0.75 mg/kg/min) and were treated by either saline or MB, at 20 mg/kg, a dose that we found to be innocuous in rat and to correspond to a dose of about 4 mg/kg in humans. MB was also administered 5 min after the end of a sub-lethal exposure to CN in a separate group of 10 rats. In addition, ATP/ADP ratio, ROS production, mitochondrial membrane potential (Δψm) and cellular O2 consumption rate (OCR) were determined in HEK293T cells exposed to toxic levels of CN (200 µM for 10 min) before and after applying a solution containing MB (1-100 µM for 10 min). RESULTS Methylene blue was found to be innocuous up to 50 mg/kg. KCN infusion (0.75 mg/kg/min) killed all animals within 7-8 min. MB (20 mg/kg) administered at the same time restored blood pressure, cardiac contractility and limited O2 deficit, allowing all the animals to survive, without any significant methemoglobinemia. When administered 5 min after a non-lethal CN intoxication, MB sped up the recovery of lactate and O2 deficit. Finally, MB was able to decrease the production of ROS and restore the ATP/ADP ratio, Δψm as well as OCR of epithelial cells intoxicated by CN. CONCLUSIONS The present observations should make us consider the potential interest of MB in the treatment of CN intoxication. The mechanisms of the antidotal properties of MB cannot be accounted for by the creation of a cyanomethemoglobinemia, rather its protective effects appears to be related to the unique properties of this redox dye, which, depending on the dose, could directly oppose some of the consequences of the metabolic depression produced by CN at the cellular level.
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Affiliation(s)
- Philippe Haouzi
- a Division of Pulmonary and Critical Care Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Maxime Gueguinou
- b Department of Physiology , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Takashi Sonobe
- a Division of Pulmonary and Critical Care Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Annick Judenherc-Haouzi
- d Heart and Vascular Institute, Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Nicole Tubbs
- a Division of Pulmonary and Critical Care Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Mohamed Trebak
- b Department of Physiology , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Joseph Cheung
- c Department of Medicine , Lewis Katz School of Medicine of Temple University , Philadelphia , PA , USA.,e Center of Translational Medicine, Lewis Katz School of Medicine of Temple University , Philadelphia , PA , USA
| | - Frederic Bouillaud
- f Institut Cochin, INSERM U1016-CNRS UMR8104, Université Paris Descartes , Paris , France
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Lim K, Heher E, Steele D, Fenves AZ, Tucker JK, Thadhani R, Christopher K, Tolkoff-Rubin N. Hemodialysis failure secondary to hydroxocobalamin exposure. Proc (Bayl Univ Med Cent) 2017; 30:167-168. [PMID: 28405068 DOI: 10.1080/08998280.2017.11929569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Hydroxocobalamin is a recently approved antidote for the treatment of cyanide poisoning. The case presented involves a young patient administered empiric hydroxocobalamin due to suspected cyanide overdose. Due to the development of acute kidney injury and severe metabolic derangement, emergent hemodialysis was initiated. Unfortunately, hemodialysis was confounded by a recurrent "blood leak" alarm. This unforeseen effect was secondary to interference from hydroxocobalamin. Hydroxocobalamin causes orange/red discoloration of bodily fluids and permeates the dialysate. This leads to defraction of light in the effluent path of the blood leak detector from discolored dialysate, which can result in activation of the blood leak alarm and an inability to continue hemodialysis treatment. This case highlights several new and emerging critical concerns with this medication, including the potential consequence of delayed initiation of emergent renal replacement therapy with empiric administration, the need for increased awareness among clinicians of various disciplines, and the need for multidisciplinary communication.
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Affiliation(s)
- Kenneth Lim
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Eliot Heher
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - David Steele
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Andrew Z Fenves
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - John Kevin Tucker
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Kenneth Christopher
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Nina Tolkoff-Rubin
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
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Dong X, Kiss L, Petrikovics I, Thompson DE. Reaction of Dimethyl Trisulfide with Hemoglobin. Chem Res Toxicol 2017; 30:1661-1663. [DOI: 10.1021/acs.chemrestox.7b00181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Xinmei Dong
- Department of Chemistry, Sam Houston State University, Huntsville, Texas 77341, United States
| | - Lóránd Kiss
- Department of Chemistry, Sam Houston State University, Huntsville, Texas 77341, United States
| | - Ilona Petrikovics
- Department of Chemistry, Sam Houston State University, Huntsville, Texas 77341, United States
| | - David E. Thompson
- Department of Chemistry, Sam Houston State University, Huntsville, Texas 77341, United States
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16
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Tan EJ, Reid CAM, Elgar MA. Predators, Parasites and Heterospecific Aggregations in Chrysomeline Larvae. Ethology 2017. [DOI: 10.1111/eth.12598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Eunice Jingmei Tan
- School of BioSciences; University of Melbourne; Melbourne Victoria Australia
- Division of Science; Yale-NUS College; Singapore City Singapore
| | - Chris A. M. Reid
- Entomology; The Australian Museum; Sydney New South Wales Australia
| | - Mark A. Elgar
- School of BioSciences; University of Melbourne; Melbourne Victoria Australia
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Bebarta VS, Brittain M, Chan A, Garrett N, Yoon D, Burney T, Mukai D, Babin M, Pilz RB, Mahon SB, Brenner M, Boss GR. Sodium Nitrite and Sodium Thiosulfate Are Effective Against Acute Cyanide Poisoning When Administered by Intramuscular Injection. Ann Emerg Med 2016; 69:718-725.e4. [PMID: 28041825 DOI: 10.1016/j.annemergmed.2016.09.034] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/16/2016] [Accepted: 09/22/2016] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE The 2 antidotes for acute cyanide poisoning in the United States must be administered by intravenous injection. In the out-of-hospital setting, intravenous injection is not practical, particularly for mass casualties, and intramuscular injection would be preferred. The purpose of this study is to determine whether sodium nitrite and sodium thiosulfate are effective cyanide antidotes when administered by intramuscular injection. METHODS We used a randomized, nonblinded, parallel-group study design in 3 mammalian models: cyanide gas inhalation in mice, with treatment postexposure; intravenous sodium cyanide infusion in rabbits, with severe hypotension as the trigger for treatment; and intravenous potassium cyanide infusion in pigs, with apnea as the trigger for treatment. The drugs were administered by intramuscular injection, and all 3 models were lethal in the absence of therapy. RESULTS We found that sodium nitrite and sodium thiosulfate individually rescued 100% of the mice, and that the combination of the 2 drugs rescued 73% of the rabbits and 80% of the pigs. In all 3 species, survival in treated animals was significantly better than in control animals (log rank test, P<.05). In the pigs, the drugs attenuated an increase in the plasma lactate concentration within 5 minutes postantidote injection (difference: plasma lactate, saline solution-treated versus nitrite- or thiosulfate-treated 1.76 [95% confidence interval 1.25 to 2.27]). CONCLUSION We conclude that sodium nitrite and sodium thiosulfate administered by intramuscular injection are effective against severe cyanide poisoning in 3 clinically relevant animal models of out-of-hospital emergency care.
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Affiliation(s)
- Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado, School of Medicine, Aurora, CO
| | | | - Adriano Chan
- Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Norma Garrett
- Medical Toxicology and the Department of Emergency Medicine, San Antonio Military Medical Center/59 MDW, San Antonio, TX
| | - David Yoon
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA
| | - Tanya Burney
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA
| | - David Mukai
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA
| | | | - Renate B Pilz
- Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Sari B Mahon
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA
| | - Matthew Brenner
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA
| | - Gerry R Boss
- Department of Medicine, University of California, San Diego, La Jolla, CA
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De Silva D, Lee S, Duke A, Angalakurthi S, Chou CE, Ebrahimpour A, Thompson DE, Petrikovics I. Intravascular Residence Time Determination for the Cyanide Antidote Dimethyl Trisulfide in Rat by Using Liquid-Liquid Extraction Coupled with High Performance Liquid Chromatography. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2016; 2016:6546475. [PMID: 28053802 PMCID: PMC5174746 DOI: 10.1155/2016/6546475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/19/2016] [Accepted: 11/13/2016] [Indexed: 06/06/2023]
Abstract
These studies represent the first report on the intravascular residence time determinations for the cyanide antidote dimethyl trisulfide (DMTS) in a rat model by using high performance liquid chromatography coupled with ultraviolet absorption spectroscopy (HPLC-UV). The newly developed sample preparation included liquid-liquid extraction by cyclohexanone. The calibration curves showed a linear response for DMTS concentrations between 0.010 and 0.30 mg/mL with R2 = 0.9994. The limit of detection for DMTS via this extraction method was 0.010 mg/mL, and the limit of quantitation was 0.034 mg/mL. Thus this calibration curve provided a tool for determining DMTS in the range between 0.04 and 0.30 mg/mL. Rats were given 20 mg/kg DMTS dose (in 15% Polysorbate 80) intravenously, and blood samples were taken 15, 60, 90, 120, and 240 min after DMTS injections. The data points were plotted as DMTS concentration in RBCs versus time, and the intravascular residence time was determined graphically. The results indicated a half-life of 36 min in a rat model, suggesting that the circulation time is long enough to provide a reasonable time interval for cyanide antagonism.
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Affiliation(s)
- Deepthika De Silva
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - Steven Lee
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - Anna Duke
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - Siva Angalakurthi
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - Ching-En Chou
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - Afshin Ebrahimpour
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - David E. Thompson
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
| | - Ilona Petrikovics
- Department of Chemistry, Sam Houston State University, 1003 Bowers Blvd, Huntsville Texas, TX 77340, USA
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Nourani MR, Mahmoodzadeh Hosseini H, Azimzadeh Jamalkandi S, Imani Fooladi AA. Cellular and molecular mechanisms of acute exposure to sulfur mustard: a systematic review. J Recept Signal Transduct Res 2016; 37:200-216. [DOI: 10.1080/10799893.2016.1212374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Mohammad Reza Nourani
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | | | - Abbas Ali Imani Fooladi
- Applied Microbiology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Betten DP, Vohra RB, Cook MD, Matteucci MJ, Clark RF. Antidote Use in the Critically Ill Poisoned Patient. J Intensive Care Med 2016; 21:255-77. [PMID: 16946442 DOI: 10.1177/0885066606290386] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.
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Affiliation(s)
- David P Betten
- Department of Emergency Medicine, Sparrow Health System, Michigan State University College of Human Medicine, Lansing, Michigan 48912-1811, USA.
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21
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Kovacs K, Duke AC, Shifflet M, Winner B, Lee SA, Rockwood GA, Petrikovics I. Parenteral dosage form development and testing of dimethyl trisulfide, as an antidote candidate to combat cyanide intoxication. Pharm Dev Technol 2016; 22:958-963. [PMID: 26740339 DOI: 10.3109/10837450.2015.1125923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study focused on the solubility enhancement and the in vivo antidotal efficacy testing of a new potential cyanide (CN) countermeasure, dimethyl trisulfide (DMTS). Various FDA approved cyclodextrins (HPβCD, RMβCD, HPγCD), cosolvents (ethanol, polyethylene glycols, propylene glycol), surfactants (cremophor EL, cremophor RH 40, sodium cholate, sodium deoxycholate, polysorbate 80) and their combinations were applied. Based on the solubility enhancing potential of the tested systems, polysorbate 80 was chosen for further in vivo efficacy studies. A composition comprising 15% polysorbate 80 and 50 mg/ml DMTS with the applied DMTS dose of 100 mg/kg provided a therapeutic antidotal protection of 3.4 × LD50. For comparison, the present therapy of sodium thiosulfate (TS) with the dose of 100 mg/kg provided only 1.1 × LD50 protection, and at the dose of 200 mg/kg, the LD50 was enhanced by 1.3 times. No difference in the therapeutic protection by DMTS was detected when the concentration of polysorbate 80 was increased to 20% (3.2 × LD50 protection). These data demonstrate the potential importance of DMTS as a CN countermeasure, and the formulation comprising polysorbate 80 provides the base of an injectable intramuscular dosage form that can later serve as a CN antidotal kit suitable for mass scenario.
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Affiliation(s)
- Kristof Kovacs
- a Department of Chemistry , Sam Houston State University , Huntsville , TX , USA and
| | - Anna C Duke
- a Department of Chemistry , Sam Houston State University , Huntsville , TX , USA and
| | - Marla Shifflet
- a Department of Chemistry , Sam Houston State University , Huntsville , TX , USA and
| | - Brittany Winner
- a Department of Chemistry , Sam Houston State University , Huntsville , TX , USA and
| | - Stephen A Lee
- a Department of Chemistry , Sam Houston State University , Huntsville , TX , USA and
| | - Gary A Rockwood
- b U.S. Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground , Aberdeen , MD , USA
| | - Ilona Petrikovics
- a Department of Chemistry , Sam Houston State University , Huntsville , TX , USA and
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 527] [Impact Index Per Article: 58.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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Petrikovics I, Budai M, Kovacs K, Thompson DE. Past, present and future of cyanide antagonism research: From the early remedies to the current therapies. World J Methodol 2015; 5:88-100. [PMID: 26140275 PMCID: PMC4482825 DOI: 10.5662/wjm.v5.i2.88] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/09/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
This paper reviews milestones in antidotal therapies for cyanide (CN) spanning early remedies, current antidotal systems and research towards next generation therapies. CN has been a part of plant defense mechanisms for millions of years. It became industrially important in the nineteenth century with the advent of CN assisted gold mining and the use of CN as a pest control agent. The biochemical basis of CN poisoning was actively studied and key mechanisms were understood as early as 1929. These fundamental studies led to a variety of antidotes, including indirect CN binders that generate methemoglobin, direct CN binders such as hydroxocobalamin, and sulfur donors that convert CN to the less toxic thiocyanate. Research on blood gases at the end of the twentieth century shed new light on the role of nitric oxide (NO) in the body. The discovery of NO’s ability to compete with CN for enzymatic binding sites provided a previously missed explanation for the rapid efficacy of NO generating antidotes such as the nitrites. Presently used CN therapies include: methemoglobin/NO generators (e.g., sodium nitrite, amyl nitrite, and dimethyl aminophenol), sulfur donors (e.g., sodium thiosulfate and glutathione), and direct binding agents [(e.g., hydroxocobalamin and dicobalt salt of ethylenediaminetetraacetic acid (dicobalt edetate)]. A strong effort is being made to explore novel antidotal systems and to formulate them for rapid administration at the point of intoxication in mass casualty scenarios. New antidotes, formulations, and delivery systems are enhancing bioavailability and efficacy and hold promise for a new generation of improved CN countermeasures.
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Chan A, Jiang J, Fridman A, Guo LT, Shelton GD, Liu MT, Green C, Haushalter KJ, Patel HH, Lee J, Yoon D, Burney T, Mukai D, Mahon SB, Brenner M, Pilz RB, Boss GR. Nitrocobinamide, a new cyanide antidote that can be administered by intramuscular injection. J Med Chem 2015; 58:1750-9. [PMID: 25650735 DOI: 10.1021/jm501565k] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Currently available cyanide antidotes must be given by intravenous injection over 5-10 min, making them ill-suited for treating many people in the field, as could occur in a major fire, an industrial accident, or a terrorist attack. These scenarios call for a drug that can be given quickly, e.g., by intramuscular injection. We have shown that aquohydroxocobinamide is a potent cyanide antidote in animal models of cyanide poisoning, but it is unstable in solution and poorly absorbed after intramuscular injection. Here we show that adding sodium nitrite to cobinamide yields a stable derivative (referred to as nitrocobinamide) that rescues cyanide-poisoned mice and rabbits when given by intramuscular injection. We also show that the efficacy of nitrocobinamide is markedly enhanced by coadministering sodium thiosulfate (reducing the total injected volume), and we calculate that ∼1.4 mL each of nitrocobinamide and sodium thiosulfate should rescue a human from a lethal cyanide exposure.
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Affiliation(s)
- Adriano Chan
- Departments of †Medicine, ‡Pathology, §Chemistry and Biochemistry, and ∥Anesthesiology, University of California-San Diego , La Jolla, California 92093-0652, United States
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Jethava D, Gupta P, Kothari S, Rijhwani P, Kumar A. Acute cyanide Intoxication: A rare case of survival. Indian J Anaesth 2014; 58:312-4. [PMID: 25024476 PMCID: PMC4090999 DOI: 10.4103/0019-5049.135045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old male jewellery factory worker accidentally ingested silver potassium cyanide and was brought to the emergency department in a state of shock and profound metabolic acidosis. This patient was managed hypothetically with use of injection thiopentone sodium intravenously until the antidote was received. Cyanide is a highly cytotoxic poison and it rapidly reacts with the trivalent iron of cytochrome oxidase thus paralysing the aerobic respiration. The result is severe lactic acidosis, profound shock, and its fatal outcome. The patient dies of cardio-respiratory arrest secondary to dysfunction of the medullary centres. It is rapidly absorbed, symptoms begin few seconds after exposure and death usually occurs in <30 min. The average lethal dose for potassium cyanide is about 250 mg. We used repeated doses of thiopentone sodium till the antidote kit was finally in our hands, hypothesising that it contains thiol group similar to the antidote thiosulphate. Moreover, it is an anticonvulsant. We were successful in our attempts and the patient survived though the specific antidotes could be administered after about an hour.
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Affiliation(s)
- Durga Jethava
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Priyamvada Gupta
- Department of Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Sandeep Kothari
- Department of Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Puneet Rijhwani
- Department of Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Ankit Kumar
- Department of Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
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Huzar TF, George T, Cross JM. Carbon monoxide and cyanide toxicity: etiology, pathophysiology and treatment in inhalation injury. Expert Rev Respir Med 2014; 7:159-70. [DOI: 10.1586/ers.13.9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gasco L, Rosbolt MB, Bebarta VS. Insufficient stocking of cyanide antidotes in US hospitals that provide emergency care. J Pharmacol Pharmacother 2013; 4:95-102. [PMID: 23761707 PMCID: PMC3669589 DOI: 10.4103/0976-500x.110875] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objective: To identify the influence of catchment area, trauma center designation, hospital size, subspecialist employment, funding source, and other hospital characteristics on cyanide antidote stocking choice in US hospitals that provides emergency care. Materials and Methods: A web-based survey was sent out to pharmacy managers through two listservs; the American Society of Health-Systems Pharmacists and the American College of Clinical Pharmacy. A medical marketing company also broadcasted the survey to 2,659 individuals. We collected data on hospital characteristics (size, state, serving population, etc.,) to determine what influenced the hospital's stocking choice. Results: The survey response rate was approximately 10% (n = 286). Thirty-eight hospitals (16%) stocked at least 4 antidote kits. Safety profile, recommendations from a poison control center, and ease of use had the strongest influence on stocking decisions. Conclusions: Survey of 286 US hospital pharmacy managers, 38/234 (16%) hospitals had sufficient stocking of cyanide antidotes. Antidote preference was based on safety, ease of use, and recommendations by the local poison center, over cost.
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Affiliation(s)
- Lucas Gasco
- Department of Pharmacy, David Grant Medical Center, CA, USA
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29
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Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm 2012; 69:199-212. [PMID: 22261941 DOI: 10.2146/ajhp110014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use. SUMMARY Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability. CONCLUSION Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.
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Affiliation(s)
- Jeanna M Marraffa
- Upstate New York Poison Center, 750 East Adams Street, Syracuse, NY 13210, USA.
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Reade MC, Davies SR, Morley PT, Dennett J, Jacobs IC. Review article: management of cyanide poisoning. Emerg Med Australas 2012; 24:225-38. [PMID: 22672162 DOI: 10.1111/j.1742-6723.2012.01538.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cyanide poisoning is uncommon, but generates interest because of the presumed utility of an antidote immediately available in those areas with a high risk of cyanide exposure. As part of its regular review of guidelines, the Australian Resuscitation Council conducted a systematic review of the human evidence for the use of various proposed cyanide antidotes, and a narrative review of the relevant pharmacological and animal studies. There have been no relevant comparative or placebo-controlled human trials. Nine case series were identified. Treatment with hydroxocobalamin was reported in a total of 361 cases. No serious adverse effects of hydroxocobalamin were reported, and many patients with otherwise presumably fatal poisoning survived. Sodium thiosulphate use was reported in two case series, similarly with no adverse effects. Treatment with a combination of sodium nitrite, amyl nitrite and sodium thiosulphate was reported in 74 patients, with results indistinguishable from those of hydroxocobalamin and sodium thiosulphate. No case series using dicobalt edetate or 4-dimethylaminophenol were identified, but successful use in single cases has been reported. Hydroxocobalamin and sodium thiosulphate differ from alternatives in having negligible adverse effects, and on the basis of current evidence are the antidotes of choice. The indications for the use of an antidote, the requirements for supportive care and a recommended approach for workplaces where there is a risk of cyanide poisoning are presented.
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Affiliation(s)
- Michael C Reade
- Australian Resuscitation Council, Royal Australasian College of Surgeons, College of Surgeons' Gardens, Melbourne, Australia.
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Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: a systematic review of existing and emerging therapies. J Am Acad Dermatol 2011; 67:e253-60. [PMID: 21821309 DOI: 10.1016/j.jaad.2011.06.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 05/20/2011] [Accepted: 06/10/2011] [Indexed: 10/17/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy, is a cutaneous ischemic small vessel vasculopathy seen in 1 to 4% of patients with chronic kidney disease on hemodialysis. It is associated with extreme pain and a 60 to 80% mortality rate in the setting of few and frequently ineffective therapeutic options, although this may be changing based on reports of success with newer therapies.
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Affiliation(s)
- Chetan Vedvyas
- Harvard Medical School, Boston, Massachusetts 02115, USA.
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Abstract
Cyanide causes intracellular hypoxia by reversibly binding to mitochondrial cytochrome oxidase a(3). Signs and symptoms of cyanide poisoning usually occur less than 1 minute after inhalation and within a few minutes after ingestion. Early manifestations include anxiety, headache, giddiness, inability to focus the eyes, and mydriasis. As hypoxia progresses, progressively lower levels of consciousness, seizures, and coma can occur. Skin may look normal or slightly ashen, and arterial oxygen saturation may be normal. Early respiratory signs include transient rapid and deep respirations. As poisoning progresses, hemodynamic status may become unstable. The key treatment is early administration of 1 of the 2 antidotes currently available in the United States: the well-known cyanide antidote kit and hydroxocobalamin. Hydroxocobalamin detoxifies cyanide by binding with it to form the renally excreted, non-toxic cyanocobalamin. Because it binds with cyanide without forming methemoglobin, hydroxocobalamin can be used to treat patients without compromising the oxygen-carrying capacity of hemoglobin.
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Affiliation(s)
- Jillian Hamel
- Division of Cardiology, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201, USA.
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Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, Brugger H, Deakin CD, Dunning J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2011; 81:1400-33. [PMID: 20956045 DOI: 10.1016/j.resuscitation.2010.08.015] [Citation(s) in RCA: 361] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S829-61. [PMID: 20956228 DOI: 10.1161/circulationaha.110.971069] [Citation(s) in RCA: 388] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Soar J, Perkins G, Abbas G, Alfonzo A, Barelli A, Bierens J, Brugger H, Deakin C, Dunning J, Georgiou M, Handley A, Lockey D, Paal P, Sandroni C, Thies KC, Zideman D, Nolan J. Kreislaufstillstand unter besonderen Umständen: Elektrolytstörungen, Vergiftungen, Ertrinken, Unterkühlung, Hitzekrankheit, Asthma, Anaphylaxie, Herzchirurgie, Trauma, Schwangerschaft, Stromunfall. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1374-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lavon O, Bentur Y. Does amyl nitrite have a role in the management of pre-hospital mass casualty cyanide poisoning? Clin Toxicol (Phila) 2010; 48:477-84. [PMID: 20653465 DOI: 10.3109/15563650.2010.505573] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Amyl nitrite has been recommended as a cyanide antidote for several decades. Its antidotal properties were initially attributed to induction of methemoglobin and later to a nitric oxide mediated hemodynamic effect. The ease of administration and alleged rapid clinical effect would recommend its wide use in the pre-hospital management of mass casualty cyanide poisoning; yet there are concerns regarding the use of amyl nitrite for this indication. OBJECTIVE Review the data on amyl nitrite in cyanide poisoning and evaluate its efficacy and safety in mass casualty cyanide poisoning. METHODS A literature search utilizing PubMed, Toxnet, textbooks in toxicology and pharmacology, and the bibliographies of the articles retrieved identified 17 experimental studies and human reports on the use of amyl nitrite in cyanide poisoning, and 40 additional articles on amyl nitrite's properties and adverse effects. One paper was excluded as it was a conference abstract with limited data. MECHANISMS OF ACTION The antidotal properties of amyl nitrite were attributed initially to induction of methemoglobinemia and later to nitric oxide mediated vasodilation. EFFICACY EXPERIMENTAL STUDIES Animal studies on the use of amyl nitrite in cyanide poisoning are limited, and their results are inconsistent, which makes their extrapolation to humans questionable. EFFICACY HUMAN STUDIES Clinical reports are limited in number and the part played by amyl nitrite relative to the other treatments administered (e.g. life support, sodium nitrite, and sodium thiosulfate) is unclear. ADVERSE EFFECTS Amyl nitrite can be associated with potentially serious adverse reactions such as hypotension, syncope, excessive methemoglobinemia, and hemolysis in G6PD deficient patients. These effects are more pronounced in young children, in the elderly, and in patients with cardiac and pulmonary disorders. Dose regimen. The method of administration of amyl nitrite (breaking pearls into gauze or a handkerchief and applying it intermittently to the victim's nose and mouth for a few minutes) is not easily controlled, might result in under- or over-dosing, can prevent the caregiver from administering life support, and possibly expose him/her to amyl nitrite's adverse effects. CONCLUSIONS Administration of amyl nitrite in mass casualty cyanide poisoning can result in unnecessary morbidity and may interfere with the proper management of the incident and the required supportive treatment and rapid evacuation. In the authors' opinion these drawbacks make the use of amyl nitrite in pre-hospital mass casualty cyanide poisoning unwarranted.
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Affiliation(s)
- Ophir Lavon
- Rambam Health Care Campus, Israel Poison Information Center, Haifa, Israel
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Vernon C, Letourneau JL. Lactic acidosis: recognition, kinetics, and associated prognosis. Crit Care Clin 2010; 26:255-83, table of contents. [PMID: 20381719 DOI: 10.1016/j.ccc.2009.12.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Lactic acidosis is a common condition encountered by critical care providers. Elevated lactate and decreased lactate clearance are important for prognostication. Not all lactate in the intensive care unit is due to tissue hypoxia or ischemia and other sources should be evaluated. Lactate, in and of itself, is unlikely to be harmful and is a preferred fuel for many cells. Treatment of lactic acidosis continues to be aimed the underlying source.
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Affiliation(s)
- Christopher Vernon
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, UHN 67, Portland, OR 97239, USA
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Leavesley HB, Li L, Mukhopadhyay S, Borowitz JL, Isom GE. Nitrite-mediated antagonism of cyanide inhibition of cytochrome c oxidase in dopamine neurons. Toxicol Sci 2010; 115:569-76. [PMID: 20335280 DOI: 10.1093/toxsci/kfq084] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cyanide inhibits aerobic metabolism by binding to the binuclear heme center of cytochrome c oxidase (CcOX). Amyl nitrite and sodium nitrite (NaNO(2)) antagonize cyanide toxicity in part by oxidizing hemoglobin to methemoglobin (mHb), which then scavenges cyanide. mHb generation is thought to be a primary mechanism by which the NO(2)(-) ion antagonizes cyanide. On the other hand, NO(2)(-) can undergo biotransformation to generate nitric oxide (NO), which may then directly antagonize cyanide inhibition of CcOX. In this study, nitrite-mediated antagonism of cyanide inhibition of oxidative phosphorylation was examined in rat dopaminergic N27 cells. NaNO(2) produced a time- and concentration-dependent increase in whole-cell and mitochondrial levels of NO. The NO scavenger 2-phenyl-4,4,5,5-tetramethylimidazoline-1-oxy 3-oxide (PTIO) reversed this increase in cellular and mitochondrial NO. NO generated from NaNO(2) decreased cellular oxygen consumption and inhibited CcOX activity. PTIO reversed the NO-mediated inhibition, thus providing strong evidence that NO mediates the action of NaNO(2). Under similar conditions, KCN (20muM) inhibited cellular state-3 oxygen consumption and CcOX activity. Pretreatment with NaNO(2) reversed KCN-mediated inhibition of both oxygen consumption and CcOX activity. The NaNO(2) antagonism of cyanide was blocked by pretreatment with the NO scavenger PTIO. It was concluded that NaNO(2) antagonizes cyanide inhibition of CcOX by generating of NO, which then interacts directly with the binding of KCN x CcOX to reverse the toxicity. In vivo antagonism of cyanide by NO(2)(-) appears to be due to both generation of mHb and direct displacement of cyanide from CcOX by NO.
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Affiliation(s)
- Heather B Leavesley
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, Indiana 47907-1333, USA
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Zemlyak I, Sapolsky R, Gozes I. NAP protects against cyanide-related microtubule destruction. J Neural Transm (Vienna) 2009; 116:1411-6. [DOI: 10.1007/s00702-009-0252-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 05/29/2009] [Indexed: 11/28/2022]
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Rockwood G, Duniho S, Briscoe C, Gold M, Armstrong K, Kahler D, Moran A, Baskin S. Toxicity in rhesus monkeys following administration of the 8-aminoquinoline 8-[(4-amino-l-methylbutyl)amino]- 5-(l-hexyloxy)-6-methoxy-4-methylquinoline (WR242511). J Med Toxicol 2008; 4:157-66. [PMID: 18821488 DOI: 10.1007/bf03161194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Many substances that form methemoglobin (MHb) effectively counter cyanide (CN) toxicity. Although MHb formers are generally applied as treatments for CN poisoning, it has been proposed that a stable, long-acting MHb former could serve as a CN pretreatment. Using this rationale, the 8-aminoquinoline WR242511, a potent long-lasting MHb former in rodents and beagle dogs, was studied in the rhesus monkey for advanced development as a potential CN pretreatment. METHODS In this study, WR242511 was administered intravenously (IV) in 2 female and 4 male rhesus monkeys in doses of 3.5 and/or 7.0 mg/kg; a single male also received WR242511 orally (PO) at 7.0 mg/kg. Health status and MHb levels were monitored following exposure. RESULTS The selected doses of WR242511, which produced significant methemoglobinemia in beagle dogs in earlier studies conducted elsewhere, produced very little MHb (mean < 2.0%) in the rhesus monkey. Furthermore, transient hemoglobinuria was noted approximately 60 minutes postinjection of WR242511 (3.5 or 7.0 mg/kg), and 2 lethalities occurred (one IV and one PO) following the 7.0 mg/kg dose. Myoglobinuria was also observed following the 7.0 mg/kg dose. Histopathology analyses in the 2 animals that died revealed liver and kidney toxicity, with greater severity in the orally-treated animal. CONCLUSIONS These data demonstrate direct and/or indirect drug-induced toxicity. It is concluded that WR242511 should not be pursued as a pretreatment for CN poisoning unless the anti-CN characteristics of this compound can be successfully dissociated from those producing undesirable toxicity.
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Affiliation(s)
- Gary Rockwood
- Analytical Toxicology Division, United States Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD 21010-5400, USA.
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Abstract
Potential carcinogenic effects, blue baby syndrome, and occasional intoxications caused by nitrite, as well as the suspected health risks related to fertilizer overuse, contributed to the negative image that inorganic nitrite and nitrate have had for decades. Recent experimental studies related to the molecular interaction between nitrite and heme proteins in blood and tissues, the potential role of nitrite in hypoxic vasodilatation, and an unexpected protective action of nitrite against ischemia/reperfusion injury, however, paint a different picture and have led to a renewed interest in the physiological and pharmacological properties of nitrite and nitrate. The range of effects reported suggests that these simple oxyanions of nitrogen have a much richer profile of biological actions than hitherto assumed, and several efforts are currently underway to investigate possible beneficial effects in the clinical arena. We provide here a brief historical account of the medical uses of nitrite and nitrate over the centuries that may serve as a basis for a careful reassessment of the health implications of their exposure and intake and may inform investigations into their therapeutic potential in the future.
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Affiliation(s)
- Anthony R Butler
- Bute Medical School, University of St. Andrews, St. Andrews, Fife, KY16 9ST, Scotland.
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Shepherd G, Velez LI. Role of hydroxocobalamin in acute cyanide poisoning. Ann Pharmacother 2008; 42:661-9. [PMID: 18397973 DOI: 10.1345/aph.1k559] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the recently approved cyanide antidote, hydroxocobalamin, and describe its role in therapy. DATA SOURCES Relevant publications were identified through a systematic search of PubMed using the MeSH terms and key words hydroxocobalamin and cyanide. This search was then limited to human studies published since 2000. Systematic searches were conducted through January 2008. References from identified articles were reviewed for additional pertinent human studies. STUDY SELECTION AND DATA EXTRACTION The literature search retrieved 7 studies on the safety and/or efficacy of hydroxocobalamin in humans. Four new studies were identified by the search and 3 studies were identified from the references. DATA SYNTHESIS Studies of antidote efficacy in humans are ethically and logistically difficult. A preclinical study demonstrated that intravenous doses of hydroxocobalamin 5 g are well tolerated by volunteer subjects. Hydroxocobalamin has been shown to reduce cyanide concentrations in controlled studies of nitroprusside therapy and in heavy smokers. A retrospective study of 14 acute cyanide poisonings also demonstrated hydroxocobalamin's safety and efficacy. Two studies examining hydroxocobalamin for smoke inhalation-associated cyanide poisoning indicated a possible benefit, but they are insufficient to establish definitive criteria for use in this setting. Randomized controlled trials of hydroxocobalamin and traditional cyanide antidotes (nitrites/thiosulfate) are lacking. CONCLUSIONS Cyanide poisoning can rapidly cause death. Having an effective antidote readily available is essential for facilities that provide emergency care. In cases of cyanide ingestion, both the nitrite/thiosulfate combination and hydroxocobalamin are effective antidotes. Hydroxocobalamin offers an improved safety profile for children and pregnant women. Hydroxocobalamin also appears to have a better safety profile in the setting of cyanide poisoning in conjunction with smoke inhalation. However, current data are insufficient to recommend the empiric administration of hydroxocobalamin to all victims of smoke inhalation.
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Abstract
The use of chemical agents as military weapons has been recognized for many centuries but reached the most feared and publicized level during World War I. Considerable political effort has been exercised in the twentieth century to restrict military strategies with chemicals. However, considerable concern currently exists that chemical weapons may be used as agents in civilian terrorism. The distribution of acetaminophen tablets contaminated with potassium cyanide and the release of sarin in the Tokyo sub-way system show that larger-scale deployment of chemical agents can be a reality. This reality makes it necessary for civilian disaster-planning strategies to incorporate an understanding of chemical agents, their effects, and the necessary treatment.
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Affiliation(s)
- Donald E Fry
- Department of Surgery, MSC10 5610, 1 University of New Mexico, Albuquerque, NM 87131, USA.
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Nitrite in nitric oxide biology: cause or consequence? A systems-based review. Free Radic Biol Med 2006; 41:691-701. [PMID: 16895789 DOI: 10.1016/j.freeradbiomed.2006.05.019] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 05/12/2006] [Accepted: 05/17/2006] [Indexed: 12/22/2022]
Abstract
All life requires nitrogen compounds. Nitrite is such a compound that is naturally occurring in nature and biology. Over the years, the pharmacological stance on nitrite has undergone a surprising metamorphosis, from a vilified substance that generates carcinogenic nitrosamines in the stomach to a life-saving drug that liberates a protective agent (nitric oxide or NO) during hypoxic events. Nitrite has been investigated as a vasodilator in mammals for over 125 years and is a known by-product of organic nitrate metabolism. There has been a recent rediscovery of some of the vasodilator actions of nitrite in physiology along with novel discoveries which render nitrite a fundamental molecule in biology. Until recently nitrite was thought to be an inert oxidative breakdown product of endogenous NO synthesis but the past few years have focused on the reduction of nitrite back to NO in the circulation as a possible mechanism for hypoxic vasodilatation. Nitrite has evolved into an endogenous signaling molecule and regulator of gene expression that may not only serve as a diagnostic marker but also find its role as a potential therapeutic agent of cardiovascular disease. These data therefore warrant a reevaluation on the fate and metabolism of nitrite in biological systems. This review serves to encompass the history and recent evolution of nitrite, the compartment-specific metabolism of nitrite and its role in plasma as a biomarker for disease, the role of nitrite as a potential regulator of NO homeostasis, and the future of nitrite-based research.
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Fry DE. Disaster Planning for Unconventional Acts of Civilian Terrorism. Curr Probl Surg 2006; 43:253-315. [PMID: 16581341 DOI: 10.1067/j.cpsurg.2006.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Donald E Fry
- University of New Mexico School of Medicine, Albuquerque, USA
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Abstract
OBJECTIVE Cyanide intoxication is an extremely rare event. We report a case of a teenager presenting with unresponsiveness, hemodynamic instability, and profound anion gap metabolic acidosis secondary to elevated lactate levels. It was later confirmed that he was a victim of cyanide poisoning. DESIGN Individual case report. SETTING Pediatric intensive care unit of a tertiary care hospital. PATIENT A 17-yr-old male presented with seizures, apnea, and cardiovascular collapse. His laboratory evaluation revealed extreme anion gap metabolic acidosis, elevated lactate levels, and absent arteriovenous saturation difference. INTERVENTIONS The patient required inotropic support and external cardiac pacing for hemodynamic instability. Serial measurements of electrolytes and arterial and central venous blood gases were performed. When cyanide poisoning was suspected he received antidote therapy, administered initially with interval dosing and then as a continuous infusion. The antidote infusions were stopped because of a high level of resultant methemoglobinemia and the belief that all ingested cyanide had been cleared, given the time from exposure. The patient never recovered neurologic function, was declared brain dead, and became a tissue and organ donor. CONCLUSION Cyanide poisoning is a rare and potentially fatal event. Prompt recognition of its possibility in a critically ill patient can lead to early intervention with antidote therapy and decrease the extent of morbidity and mortality.
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Affiliation(s)
- Stacie B Peddy
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
Cyanide is both widely available and easily accessible throughout the world. Although the compound is not frequently encountered, it has been used as a poison and contaminant in the past and is a potential terrorist agent. Cyanide has the ability to cause significant social disruption and demands special attention to public health preparedness. It can be obtained from a variety of sources, including industrial, medical, and even common household products. Another frequently encountered source of cyanide exposure is residential fires. Exposure to high concentrations of the chemical can result in death within seconds to minutes. Long-term effects from cyanide exposure can cause significant morbidity. The only treatment for cyanide toxicity approved for use in the United States is a kit consisting of amyl nitrite, sodium nitrite, and sodium thiosulfate. Future research aims to find a faster-acting, more effective, and better tolerated treatment for cyanide toxicity.
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Affiliation(s)
- Rebeca Gracia
- North Texas Poison Center, Dallas, Texas 75235, USA.
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