Successful Use of Hydroxocobalamin and Sodium Thiosulfate in Acute Cyanide Poisoning: A Case Report with Follow-up
Abstract
Hydroxocobalamin is an effective first-line antidote used mainly in monotherapy of cyanide poisonings, while the opinions are different on the effects of its combination with sodium thiosulfate. A 58-year-old male committed a suicide attempt by ingesting of 1200-1500mg of potassium cyanide; he was unconscious for 1-1.5min. after ingestion with the episode of generalized seizures.
On admission to the ICU, the patient was acidotic (pH 7.28; HCO3 14.0mmol/L, base excess -12.7mmol/L, saturation O-2 0.999) with high serum lactate (12.5mmol/L). Hydroxocobalamin was administered 1.5hr after ingestion in two subsequent intravenous infusions at a total dose of 7.5g.
The infusion was followed by continuous intravenous administration of 1mL/hr/kg of 10% sodium thiosulfate at a total dose of 12g. No complications and adverse reactions were registered.
Serum lactate decreased to 0.6mmol/L the same day, and arterial blood gases became normal (pH 7.49; HCO3 27.2mmol/L, base excess 2.2mmol/L, saturation O-2 0.994). The follow-up examination 5months later revealed no damage of basal ganglia and cerebellum on magnetic resonance imaging.
The neurological examination revealed no pathological findings. On the ocular coherence tomography, the retinal nerve fibres layer was normal.
In visual evoked potentials, there was a normal evoked complex on the left eye and minor decrease in amplitude on the right eye. Combination of hydroxocobalamin and sodium thiosulfate can have a positive effect on the survival without long-term neurological and visual sequelae in the cases of massive cyanide poisonings due to the possibility of a potentiation or synergism of hydroxocobalamin effects by sodium thiosulfate.
This synergism can be explained by the different time-points of action of two antidotes: the initial and immediate effect of hydroxocobalamin, followed by the delayed, but more persistent effect of sodium thiosulfate.