Cyanide Antidote Kits
An ongoing discussion from 2002 through 2014 . . .2002
Q. I have a gold plating system. I need to purchase a Cyanide Antidote Kit. Can anyone tell me where to find one?
Thanks Kitty H.Kitty Howard
- Overton, Nevada
A. The one ingredient in the kit that is administrable without injection or professional help is amyl nitrite capsules, a controlled dangerous substance (poppers). So you'll need a doctor's prescription for the kit, and you may have trouble finding a willing doctor.
The second problem is that your pharmacist may not be familiar with this law or the kits (been there / done that).
Your third problem is you can't leave a controlled dangerous substance like this available. So you have to mount it behind tempered glass with one of those little hammers like on some old fashioned fire alarm stations.
The trick may be to start at your regional poison control center -- they have such kits. Get a note from them for your doctor and instructions on how to order the kit (I think it's distributed by Eli Lilly); take the note to your doctor and he'll give you the prescription; give the prescription and the ordering info you got from the poison control center to your pharmacist. You must make the effort because OSHA does not hesitate to fine an employer for failing to have a cyanide antidote kit.
Ted Mooney, P.E.
Pine Beach, New Jersey
Striving to live "Aloha"
A. It's not easy to convince a doctor you need a kit but I have had pretty good luck getting prescriptions for cyanide antidote kits from doctors at occupational medical clinics, and the clinic I am using also orders the kits for me. The kits are made by Taylor pharmaceuticals. I hope this helps
Red Sky Plating
Albuquerque, New Mexico
A. This is a very serious matter to anyone handling cyanides. I can only speak from the UK's perspective, but it may be of use. Firstly the health and safety people here do not like non-qualified people sticking needles into other people and anyone doing so can be done for assault. Secondly the cyanide antidote kit contains both amyl nitrite and two solutions (A&B) that you mix and give to the patient to drink (if conscious) as an antidote. There is also the cobalt edetate in glucose and sodium thiosulphate solutions for injection. The orally administered antidote is of non-proven effectiveness, but (I suppose) is better than nothing. Injections can ONLY be given by qualified people (i.e., doctor, nurse, paramedic etc).
However, the latest Health and Safety guidelines in the UK say the ONLY thing to do is to administer oxygen from a medical oxygen gas cylinder; this can be done by anyone who has been trained in the requisite First Aid. Obviously seeking immediate medical help is paramount. Finally, there is some debate as to whether the whole antidote process is actually of any use after a real potentially fatal exposure; the treatment is so extreme that some people consider it to be as hazardous as the cyanide.
R&D practical scientist
Chesham, Bucks, UK
A. I just wanted to make everyone aware. Keystone Pharmaceuticals manufactures Cyanide Antidote Kits. I hope this helps. We do require a DEA certificate for purchases or you could have a physician place an order for you.Jesse Suarez
Keystone Pharmaceuticals Inc - Laguna Hills, California
Ed. note: please see entry of Oct. 4, 2010 regarding the FDA declaring cyanide antidote kits "Unapproved Drugs" and raiding Keystone and seizing their stock.
February 24, 2010
Q. How does a first responder/lay person at a site determine when to use the amyl nitrite? How do they separate symptoms an employee may be having from those of other medical conditions? What training do they receive as to when and how to use the medication?Elaine Lochem
- Waterford, Connecticut
April 14, 2010
A. Hi, Elaine. The capsules are used only as smelling salts. You can't inject anything without medical training, and you can't force a patient to drink anything -- either s/he's conscious and wants to drink it or not.
The strongest indicator of cyanide poisoning might be situational (what went on that indicates cyanide poisoning probably did or did not occur; is the cyanide detector activated or silent?) rather than symptomatic. But other indicators for a non-medically trained person like myself would be the burnt almond smell,
blue coloration of lips and finger nails ^[see Oct. 6, 2010] , and lack of oxygen in the blood.
The main reason for having the capsules is probably to adhere to U.S. law rather than to use them. As you read above, some other countries believe oxygen is a better idea and, although I have no medical training, at this point I would have to agree that the present situation makes little sense.
Ted Mooney, P.E.
Pine Beach, New Jersey
Striving to live "Aloha"
April 14, 2010
RFQ: Dear sirs,
I need cyanide antidote kit or just amyl nitrite capsules,
is there anyone can tell me where can I buy cheaper?
- Ulaanbaatar MONGOLIA
October 4, 2010
Q. Does anyone know where in the OSHA regulations that an antidote kit is required? So far, I have not found one.
I did purchase a kit for our company, but would like to justify the purchase based on an OSHA document. We did coordinate with the emergency service providers and hospital but we can not administer nor can the ambulance crews administer the drugs! Thanks
- Lisbon, New Hampshire USA
October 4, 2010
A. Hi, Jim.
The cyanide antidote requirement was, as I recall, in section 1910.126. I don't know if it is still there, but I do know of plating shops that were fined for not having one. One of the incriminating pieces of evidence against the accused in the popular book "The Cyanide Canary" was (page 78) that "In 1988, OSHA cited AEI, Inc., for failing to have a cyanide antidote kit on the premises".
Here in New Jersey, you can see NJ Dept. of Health and Senior Services "Hazardous Substance Fact Sheets" that say, with respect to hydrogen cyanide: "Use Amyl Nitrite capsules if symptoms develop. All area employees should be trained regularly in emergency treatment of Cyanide poisoning and in CPR. A Cyanide antidote kit MUST be rapidly available and ingredients replaced every 1 to 2 years to ensure freshness." (their emphasis, not mine).
In West Virginia: "Cyanide antidote kit must be kept in immediate work area. Persons trained in the use of this kit, oxygen use, and CPR must be available within 1-2 minutes."
Many MSDS explain that a cyanide antidote kit is required, and you could hardly claim that the chemical is being properly handled if the stated requirements on the MSDS are not being met.
opinion! BUT, just to let you know that the situation gets ever more ludicrous, according to MedpageToday.com, July 23, 2010, the "FDA Calls Cyanide Antidote Kits Unapproved Drugs" and seized Keystone Pharmaceutical / PrimaPharm's stock of the kits (https://www.medpagetoday.com/ProductAlert/DevicesandVaccines/21353). So, you bought the kit to be in compliance with the law, but now those kits are "unapproved drugs" that the FDA wants to seize from you.
The FDA's Michael Chappell is quoted at http://www.cbc.ca/health/story/2010/07/23/con-cyanide-kits.html:
"This action is a significant step in protecting public health."
Oh, so VERY significant, Michael! Swarms of armed OSHA bureaucrats living on the public dole force employers to buy these antidote kits, then in full Keystone Cop fashion, a different swarm of armed mindless bureaucrats raid the facilities that offer them, and make it a crime to comply with the law. And Chapell, instead of profusely apologizing to we taxpayers for this utter incompetence and shameful waste of taxpayer money, wants "credit" ... no joke, he wants CREDIT!!! :-)
And we citizens wonder why...
... we see one manufacturing facility after another shuttered across America, while these nincompoops are never held responsible ...
... we see record intractable and permanent unemployment ...
... we quietly watch the razing of "The Arsenal of Democracy" that our parents and grandparents so proudly built, and which won two World Wars, and watch it replaced by "The People's Arsenal" in China.
Sorry, but the future of America is in deadly peril every single day we let dangerous buffoons like Chappell run amok.
Good luck and Regards,
Ted Mooney, P.E.
Pine Beach, New Jersey
Striving to live "Aloha"
Update: The revolving door continues to revolve, and that former acting director is back to representing big pharma yet again; meanwhile we're on to the next pharma industry lobbyist "regulating" (cough) the industry. Our corrupt politicians repay campaign donations by letting industry lobbyists control the FDA, FCC, and the other regulatory agencies. You can't make this stuff up; big money and corrupt hacks are turning America into a banana republic :-)
October 6, 2010
A. A number of cyanide treatments are in use worldwide. Unfortunately, there is no agreement on the most acceptable treatment in an immediate incident situation, largely driven, I believe, by a paranoid fear of litigation.
There is therefore no practical advice I can offer except to take advice from your local safety authority.
I would, however, like to correct the perception that a blue colouration of the lips etc is a symptom of cyanide poisoning.
Extract from an old paper of mine --
- The term cyanosis has caused some confusion in the context of cyanide intoxication. Cyanosis describes a bluish skin coloration, symptomatic of asphyxia and caused by a lack of oxygen in the blood. The word derives from the Greek "kynos"; a dark blue mineral (OED). Clinical experience of cyanide intoxication is rare and it is therefore not surprising that the term has been assumed to describe its symptoms. It will be shown that this is not the normal observation and patients are described as having a rather pinkish complexion. No proof can be offered, but it is suggested that the philological connection originates in the original synthesis of hydrogen cyanide from Prussian Blue. It has also been reported that the use of methylene blue or tolidine blue in antidote therapy can give rise to a bluish skin coloration. -
October 12, 2010
A. I'm a HazMat Paramedic for a large metropolitan city. We carry several cyanide antidote kits on our ambulance, and we do use them periodically. Without getting deep into the pathophysiology of cyanide poisoning, the end result of the poisoning is the inability of the blood and more specifically the hemoglobin to transport oxygen. Administering oxygen without reversing the cause is absolutely useless. The "poppers" are a quick way to start the reversal, but are only capable of reversing approx. 5% of the effects. The IV meds of the standard kit are required to effect any further change. The Cyanokits are definitely better in that they have much fewer possible serious side effects, but they are extremely cost prohibitive, and also have a very short shelf life.....a bad combination. Cyanide poisoning is found to be the cause of death in a lot of victims of house fires due to combustion of various household items. This is why newer monitors are being deployed by EMS services and fire departments that allow us to obtain methemoglobin readings to help us ascertain the need to administer the kits.John Sippel
- Universal City, Texas
October 13, 2010
A. Sorry but the hemoglobin mechanism is another widely believed but entirely wrong idea.
At the risk of a rather lengthy reply I can only quote
...Within the metal finishing industry, the toxicity of cyanides is a common subject of discussion and it was a suspicion that, not only was the most commonly expressed view wrong, but that it was affecting the direction of process development, that was a major factor in initiating this current project.
The general perception may be hypothesised as:-
Cyanide is a blood poison which attaches irreversibly to the iron in haemoglobin to prevent the carriage of oxygen.
The effect of cyanide is extremely rapid (minutes) and fatal at extremely small dosage.
Antidotes are only marginally effective and must be administered immediately to have any chance of success.
These assumptions may be readily challenged:-
In cases of cyanide poisoning, the venous (return) blood is a rich red colour. i.e. it contains an adequate supply of oxygen but this has not been delivered to the body.
There is evidence in the literature documenting a high recovery rate.
In view of the current drive towards ever improved safety, health and environmental standards it is important that both the industry and its regulators should have a sound understanding of all aspects of the toxicology of both cyanide and of any proposed alternatives.
The literature published on the toxic effects of cyanide is vast. However, current standard safety texts have proved disappointing in giving only the briefest treatment with poor descriptions of the mechanism of action. A comprehensive description was obtained from texts on cell biology and a report on antidotes which also emphasises the importance of the body's natural defence mechanisms as the basis of most antidote therapy. Alberts et al (n.d.)21, Meredeth et al (1993)22.
Medical texts record few accidental fatalities and report many cases of full recovery. The scarcity of fatalities within the industry is supported by the records of the Health and Safety Executive indeed, HSE cites US references for accidents. Acceptable workplace exposure to harmful chemicals is published annually by HSE in EH4023. This defines legal maximum exposure during the normal working day but is of little use in estimating effects in the case of an accidental exposure. i.e. it is based on the NOAE level with a considerable safety factor. The dose / effect relationship of ingested cyanide is well recorded but release of hydrogen cyanide gas will be shown to be a credible mechanism for accidental exposure. Safety texts offer little guidance here. However, early workers published some quantified data, often at considerable personal risk 1. Little has been added to the literature since the 1940s but up to that time the use of hydrogen cyanide was studied - and sometimes deployed - as a war gas. Military sources have therefore been accessed in this area. In particular, McNamara (1976)24 collated a comprehensive survey of the data and notes that he was unable to trace a copy of the primary data published by Lehman (pre 1921), which is still currently cited in the majority of standard texts. Much of the available data for human exposure is old and was obtained at a time when a more robust approach to toxicity
Toxicology of Cyanides
Although cyanides are universally known as highly toxic chemicals, there is widespread ignorance or misunderstanding of the mechanism and kinetics of their action within the body. In conversation with a well known metal finishing consultant, it was stated that '...death is usually caused by a fractured spine.' (presumably from the type of severe spasm often attributed to strychnine poisoning). Such views may be due to cyanide having long been the crime writer's favourite poison and common film portrayals of instantaneous demise from the most trivial dose. It is, however, arguable that this view may have a positive effect and the rarity of accidental cyanide poisoning in industry owes much to the awe in which it is regarded. More commonly, it is widely held in the technical community that cyanide attaches to haemoglobin in the blood to form cyanhaemoglobin which defeats the oxygen carrying function2 . Such a mechanism would be similar to the known effect of carbon monoxide and would imply a similar degree of toxicity. However, the effects of cyanide are much more severe than carbon monoxide and death occurs before the blood oxygen capacity has been sufficiently impaired to cause asphyxiation.
The toxicity of certain plants has been recognised from the earliest times. Vennisland p. 1 (1981)25. Cyanide is the active element in peach kernels and bitter almonds recorded in Egyptian and Greek texts. Cherry Laurel leaves and Cassava were also known in antiquity but the chemical basis of their toxicity was not recognised.
It is generally accepted that the first synthesis of hydrogen cyanide was due to the Swedish chemist Scheele (1782) during investigation of the dye Prussian Blue. He did not name his discovery or note any poisonous properties but recorded that '...This matter has a peculiar but not disagreeable smell, a taste somewhat approaching to sweet and warm in the mouth, at the same time exciting cough.' The name prussic acid was first applied by Guyton de Morveau (1789) from its original source and in 1789 Berthelot determined the composition as containing carbon, hydrogen and nitrogen. This was a significant contribution to chemical knowledge at that time as previously it was believed that all acids necessarily contained oxygen. The connection between the new acid and known plant toxins was made by Schraeder (1802). Vennisland ibid. (1981)25.
Early animal experiments with the plant derived poisons date from the seventeenth century and observations were made on the mode of action. From the beginning of the nineteenth century, synthetic cyanide preparations replaced plant extracts and their toxic and therapeutic effects were vigorously studied. In view of the current attitude towards cyanides, it is pertinent to note that they saw considerable application in the treatment of pulmonary complaints and were only removed from the British Pharmacopoeia in 1948. Vennisland ibid. (1981)25.
The mid part of the nineteenth century saw the establishment of toxicology as an established discipline with quantitative methodology and increasingly rigorous recording and referencing of work. Hoppe - Steyre (1876) showed that cyanide inhibited tissue oxidation preventing the reduction of oxyhaemoglobin in the blood to its darker form on passing to the venous system. Batelli and Stern confirmed this in 1907 and showed that the reaction could be reversible supporting earlier observations on the use of artificial respiration. The formation of thiocyanate in cases of cyanide poisoning (Lang 1994) led to the discovery of the enzyme rhodenase by (another) Lang in 1933 as the basis of the body's primary detoxification mechanism. Vennisland ibid. (18)25
Mechanism of cyanide toxicity.
The following section summarises the current state of knowledge of the mechanism of cyanide within the body
Inhaled hydrogen cyanide passes almost immediately into the bloodstream where it is distributed throughout the body in about 2 minutes . Ingested cyanide is absorbed into the bloodstream via the stomach and gut lining. However, the rate of absorption depends heavily upon the condition within the stomach at the time of ingestion. The presence of a large volume of food effectively dilutes the dose while the rate of release of cyanide ion depends on the prevailing acidity. Ballantyne and Mars (1987)20.
Having entered the blood, the subsequent route for inhaled, ingested or absorbed cyanide is common. Cyanide and oxygen are distributed by the blood to cells throughout the body and both migrate into the cell structure by transport along a concentration gradient. With the exception of red blood cells, practically all cells are eucaryotic i.e. contain a structure known as the nucleus and a smaller structure, the mitochondrion. The mitochondrion is of crucial importance to the function of the entire organism since it is the site where energy is generated by the oxidative conversion of adenosine diphosphate (ADP) to adenosine triphosphate (ATP) Alberts et al (n.d.)21 p662. The reaction is reversible and the return of ATP to ADP releases much of the energy which fuels the essential inter and intra cellular activity. This reaction may be considered to be the main driving force of life itself and its disruption will inevitably be critical. In order to enter the mitochondrion, oxygen must traverse the mitochondrial membrane. This is achieved via a group of at least eight enzymes the cytochrome b - c1 complex. ibid. pp677 et seq. The cytochrome molecule contains a bimetallic centre consisting of one copper and one iron atom which bond to the oxygen and carry it across the cell membrane, ibid. p 679. Any cyanide present forms an extremely strong bond with the iron atom, prevents the oxygen transfer and hence the generation of energy by the ATP/ADP reaction. The greatest energy users are the cells of the muscle tissues and neural fibres. The organism thus suffers asphyxiation at the cellular level and death will rapidly follow unless the problem can be reversed. The high energy requirement of muscle (particularly cardiac muscle) and neural tissues explain the observed symptoms of cyanide poisoning, deep and irregular breathing as the body seeks to obtain more oxygen followed by suppression of breathing and cardiac function as it fails to do so.
The median lethal dose of cyanide (LD50) in man is stated by Lewis (1995)27 as 3mg/kg. However Wallace Hayes p10 (1982)28 expands at some length the problems of using this as a critical measure of toxicity. Dose /response curves for toxic substances are not linear, particularly where the body has a defence mechanism or a threshold dose must be exceeded before a response is observed. LD50 is a statistically derived dose obtained from animal experiments. It is sensitive to, inter alia, species, sex, dose rate, pre-existing conditions and feeding regime prior to dosing. Some of the problems of equating animal experiments to human response are discussed later. The concept of LDlo, the lowest observed lethal dose, is also used, but suffers from anomalies introduced by particularly susceptible individuals.
A similar mechanism makes cyanide toxic to most plants and other aerobic organisms. Solomonson in Cyanide in Biology, Venisland (1981)25 p. 14 comments that 'cyanide is a rather common metabolite which can be formed from a variety of precursors which are widely distributed in nature'. This is particularly so in parts of the world where cassava forms a major part of the diet. This and many other potential human and animal foodstuffs contain cyanidic glycosides which hydrolyse to cyanide in the gut. Cyanide is also present in automotive exhaust gasses and tobacco smoke and is considered a to be a normal constituent of blood.
Although not mentioned by any of the safety literature seen, the body has a considerable endogenous capacity to detoxify cyanide. First discovered by Jaffe (1877), it was shown by Lang (1933) to be dependent on the enzyme rhodinase which controls the reaction of cyanide with thiosulphate to form much less toxic thiocyanate. The endogenous supply of available sulphur is limited and injection of sodium thiosulphate is an important part of the accepted treatment of cyanide poisoning.
CN- + S 2 O3 => SO3 + SCN- => Excretion via urine.
Other less significant detoxification routes are also known such as excretion of hydrogen cyanide via the lungs and binding to cystine or hydroxocobalamin. Meredith et al (1993)22 p7.
These mechanisms have several practical effects:-
The body will tolerate low doses of cyanide.
Tolerance to ingestion may be increased if absorption is delayed by favourable stomach conditions.
Low concentrations of hydrogen cyanide may be tolerated for extensive periods where the same time/concentration product inhaled at higher concentration for less time could be dangerous.
Supportive treatment alone may gain sufficient time for a patient to recover....
If anyone would like a copy of the paper which contains full references and quantitative environmental and safety risk assessments it was published in the Transactions of the Institute of Metal Finishing (Trans IMF) - see the link on this site, or ask Ted for my email address and I will send a copy.
Aug. 21, 2011
A. I noted that you expressed an interest in the Cyanide Antidote Kit in Forum Letter #17072. The Food and Drug Administration recently approved a cyanide antidote kit with the brand name Nithiodote that contains sodium nitrite injection and sodium thiosulfate injection. Prescribing information is available online at www.nithiodote.com. Any pharmacy can dispense a kit to a finishing facility on the presentation of a prescription.
Please consider sharing this information with your community on finishing.com. Also, please contact me if you have any questions.
Craig Sherman, M.D.
August 10, 2012
Q. After reading all the above, and spending some time on the OSHA website, I cannot find any requirement to have a cyanide antidote kit on hand at our metal finishing facility. Can anyone update this post? And if there is such a requirement, does anyone know who is making them and how to get it?Jennifer Masse
- Buffalo, New York, USA
August 10, 2012
A. Hi, Jennifer. I am not able to easily find that requirement anymore either. I believe it was originally in section 1910.126 under the requirements for diking for cyanide, or maybe under the ventilation requirements for cyanide, almost as a parenthetical addition. It doesn't seem to be there anymore and I can't see any info on google about when it was removed, although a literature search of industry trade journals might dig it up. One of the things I mentioned in my posting of October 4, 2010 was that it is still required in New Jersey, and many other states today; so check with New York because the situation may be similar.
Please see the posting immediately above yours for a source. Good luck.
Ted Mooney, P.E.
Pine Beach, New Jersey
Striving to live "Aloha"
December 19, 2012
A. Good afternoon to all.
I readily have kits available for export ONLY. That means that I can only ship cyanide antidote kits outside of the United States. The FDA has regulated the kit in the United States to where it is currently unavailable. I understand that a majority of kits have just expired in the end of November, 2012 and demand is high in the United States. As a direct distributor for the manufacturer (Akorn), my colleagues and I have been fielding numerous calls from pharmacies, hospitals, and companies that need the kit available for their workers at a moment's notice.
We are currently working on a solution to the problem. I can be contacted at my sales office to discuss future possibilities in obtaining a cyanide antidote kit. Google, 'ABO Pharmaceuticals' and ask for Blake when you call.
ABO Pharmaceuticals - San Clemente, California, USA
July 30, 2014
My name is Shyam Sunder, I am looking for a buyer who needs Cyanide antidote kits in Russia & Rest of CIS. We at Troikaa manufacture and sell these kits to many countries.The contents of the Kit is as mentioned below
1, 2 ampoules of Sodium nitrite Injection USP 300 mg in 10 ml of sterile water for injection
2, 1 vial of Sodium thiosulfate injection USP, 25 gm in 50 ml of sterile water for injection.
3, 12 durules of Amyl nitrite Inhalant, 0.3 ml.
4, 1 sterile 10 ml plastic disposable syringe with 22 gauge needle.
2 sterile 50 ml plastic disposable syringe with 22 gauge needle.
1 stomach tube
3 sterile disposable needles
1 set of instruction for the treatment of cyanide poisoning
1 additional information on Cyanide Antidote.
If someone has contacts in Russia & CIS they can contact me.
Troikaa Pharmaceuticals Ltd, Formulations & Orphan drugs - Ahmedabad,Gujarat, India
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