Podcast 122 – Cardiac Arrest after the Toxicology of Smoke Inhalation with Lewis Nelson - a podcast by Scott D. Weingart, MD FCCM

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...

Further episodes of EMCrit Podcast

Further podcasts by Scott D. Weingart, MD FCCM

Website of Scott D. Weingart, MD FCCM