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New update 4/2019


Cyanide Toxicity / Smoke Inhalation


5 gm IVPB / IO


Cyanide Toxicity / Smoke Inhalation


70 mg/kg IV/IO over 15 min (Max of 5 gm)


Hydroxocobalamin binds with cyanide and limits cyanide interfering with body tissue energy production



  • Cyanide toxicity, known or suspected

  • Smoke inhalation, smoke generated from burning plastics or petroleum products



Known allergy to hydroxycobalamin.



1. Make Base Hospital contact for hydroxocobalamin order and possible burn center destination.


2. Mixing instructions for hydroxocobalamin supplied in a Cyanokit®:

     A.  Identify the 250 ml glass vial containing 5 g of lyophilized hydroxocobalamin.

     B.  Place vial in an upright position. Add 200 ml of 0.9% normal saline to the vial using the

             transfer spike. 

     C.  Repeatedly invert and rock vial (do not shake) for approximately 60 seconds.

     D.  When solution is dark red in color and no particles are visible, it is appropriate for infusion.


3. Patient management:

     A.  Remove the individual from the environment

     B.  Assess ABCs and mental status and provide airway support as needed.

     C.  Apply high-flow oxygen by mask or nasal cannula as tolerated.

     D.  Establish IV/IO access

     E.  Infuse hydroxycobalamin IV/IO over approximately 15 minutes

          Pediatric dose = 70 mg/kg IV/IO over 15 minutes, maximum 5 grams

     F.  Do not simultaneously administer other medications with hydroxycobalamin through the same

     IV/IO site. 



1.  Use of hydroxycobalamin can cause the skin and mucus membranes to turn a reddish color.  Allergic

reactions have also been reported.  Therefore, inform receiving facilitythat hydroxocobalamin was administered in the field prior to arrival.

2.  Increases in blood pressure may be observed and expected following hydroxocobalamin infusion.

PEDS - Hydro
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