Cyanide antidote kit gains federal approval

By Amanda Milkovits
Providence Journal

PROVIDENCE — The U.S. Food and Drug Administration has approved a cyanide antidote kit that can be carried on ambulances and stocked in hospital emergency rooms to save lives of firefighters and civilians who inhale toxic smoke.

The approval comes nine months after several Providence firefighters suffered from cyanide poisoning after inhaling smoke at structure fires. One of the firefighters, Kenneth Baker, had a heart attack and nearly died. He is still off duty and recovering at home.

The nearly odorless hydrogen cyanide gas is an invisible killer that's emitted in smoldering and burning synthetics or plastics, most often common household goods, or foam, asphalt and construction material. Inhaling cyanide can cause headaches and dizziness, or seizures and death in a matter of minutes to hours.

While smoke inhalation is responsible for up to 80 percent of fire-related injuries and deaths in the United States, there's no definitive study of how many injuries or deaths are caused by cyanide poisoning. Few hospitals test for cyanide, mainly because the results take longer than the time needed to save the patient. Battalion Chief Thomas Warren and Deputy Assistant Chief J. Curtis Varone said they've been urging hospitals here to test smoke-inhalation victims for cyanide so they can gain an understanding of the prevalence of the problem.

Baker and other firefighters were given an antidote for cyanide by a Rhode Island Hospital emergency room physician who quickly recognized the signs of cyanide poisoning. That antidote, the only one on the market in the United States, is a kit that can be administered only in a hospital because it causes serious side effects, including severe low blood pressure, and can kill if given to someone who is misdiagnosed.

The new antidote, Cyanokit, is safe enough to be given to victims at the scene of a fire — and works fast enough to save lives in minutes, according to the manufacturer, Merck KGaA of Germany. The antidote would be given to smoke-inhalation victims who are dizzy, confused or lapsing into a coma — a sign of cyanide poisoning.

Cyanokit contains hydroxocobalamin, a precursor to vitamin B-12, which binds to cyanide and neutralizes it so the poison is no longer toxic and can be eliminated harmlessly from the body through urination. The drug is given intravenously and acts immediately. Some side effects include temporary discoloration of the skin and urine.

This is the same antidote that's been used for years by firefighters in France and some other European countries, but never here. Cyanokit was introduced to the FDA this summer by EMD Pharmaceuticals Inc. and will be marketed by Dey LP, both U.S. affiliates of Merck KGaA. Cyanokit is expected to be on the market nationwide early next year, said Elliott Berger, vice president of regulatory affairs for EMD Pharmaceuticals Inc. The cost has not been determined yet, he said.

"This is great news," said Varone, who led the Providence Fire Department's cyanide task force that urged approval of the new antidote.

Cyanokit will still need the approval of the Rhode Island Department of Health before it can be stocked on ambulances here.

The state EMS board, which approves the medications carried on the ambulances, will write a protocol with the state medical director, said Health Department spokeswoman Maria Wah-Fitta. The state Ambulance Service Advisory Board will also weigh in. Once both boards reach agreement, the state will set a date to implement the new protocols and train the 4,300 emergency-medical technicians in Rhode Island, she said. The entire process could take at least a month.

Until Baker's collapse, few in the fire service had heard about cyanide poisoning from smoke. Now, fire departments are working to protect firefighters from the poison, from buying air-supply trucks so firefighters can refill airpacks quickly to ordering cyanide-detection kits for the firefighters to wear inside and outside fire scenes.

The Providence Fire Department is buying $300 to $400 detection systems for every fire truck, so the lead officers can alert their companies when cyanide is present, Varone said.

They've tested one kit over the last several months. "No surprise," Varone said. "We've found cyanide at every fire we've been to."

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