Page 218 - 2022 Ranger Medic Handbook

Cyanide Tx: Hydroxocobalamin (vitamin B12a) complexes with cyanide to form cyanocobalamin (vitamin B12). Requires
IV access. 150mg/kg (4500mg or 1 cyanokit). It must be reconstituted/shaken for 30 seconds. More effective when com-
bined with sodium thiosulfate 12.5g IV over 30 minutes. Second treatment option requires a two-step process: 1) amyl
nitrite (crush an ampule and find a way to get the dog to inhale) or sodium nitrite at 300mg IV or IO over 5–10 minutes.
These agents create a methemoglobinemia. The ferric ion (Fe 3+ ) in methemoglobin has a higher affinity for cyanide than
the cytochrome oxidase molecule in the mitochondria. 2) sodium thiosulfate (12.5g over 30 minutes) which is a sulfur
donor. The sulfur is used as a substrate to eventually convert cyanide to thiocyanate. Remember, the antidotes have to
be given slowly, nitrite can cause hypotension and too much will overproduce methemoglobin causing a decrease in
oxygen carrying capability. Administration of 100% O 2 is significantly helpful despite the fact that the poison prevents
the use of oxygen in cellular respiration. Mechanical ventilation may be needed, circulatory support with crystalloid fluid
administration, vasopressors if fluid administration does not correct hypovolemia. Dopamine at 10mcg/kg/min is prob-
ably ideal as it is a less potent inotrope than epinephrine or dobutamine and less vasoconstricting than norepinephrine.
Decontamination of Cyanide: Self-protection and then remove animal from the exposure source to fresh air. Dermal
absorption does not occur and the substance is highly volatile. Decontamination is generally unnecessary unless liquid
contamination has occurred to the coat. If this occurs, wash with water alone or water and soap.
Opiate Toxicity Signs: May occur if the animal is exposed to heroin or fentanyl/carfentanyl when clearing a building that
turns out to be a drug facility or has a drug cache. Could be a weaponized agent someday. Occurs within 1–2 minutes
by inhalation, 1–2 hours by ingestion. Altered mental status, animal may look dizzy or lethargic and end up in a coma,
hypersalivation, hyperthermia, ataxia, bradycardia (normal HR 70–120), hypotension (normal systolic BP > 90mmHg,
MAP > 65mmHg), hypoventilation, neck rigidity, and seizures.
Opiate Toxicity Tx: Naloxone is a pure opiate antagonist. It reverses most of the effects of high-dose opiate administra-
tion to include respiratory and CNS depression. Dose in dogs is 0.04mg/kg to 0.1mg/kg (or about 1.2mg to 3mg for
an MPC) IV, IN (atomizer), IM, SQ recommendation is to give a ¼ of the max dose and repeat every three minutes until
desired affect is achieved (half-life is about 1 hour in humans). Naltrexone 2–5mg/kg (60–150mg for an MPC) PO q24hr
may be used when injectable naloxone is not available. Nalmefene 0.03mg/kg (0.9mg) IV has a much longer plasma
half-life (11 hours) than naloxone. It is no longer available in the United States. It is/was used as an opiate reversing agent
and to manage human alcohol dependence and addictive behaviors.
SECTION 6 Choking Agent Signs: Ammonia, chlorine, phosgene, HC smoke, PFIB (perfluoroisobutylene), nitrogen oxide and phos-
gene. Ammonia (as well as sulfur mustard) work on the central airways and burn the tissue. This can cause laryngo-
spasm and eventual collapse. Sulfur mustard will block airways when pseudomembranes slough off within the airway.
The others are all peripheral acting agents except for chlorine which affects the patient peripherally and centrally. PFIB
is released when Teflon burns (lines many military vehicles). Nitrogen oxide is released when gunpowder burns. Central
agents tend to have immediate effects that include laryngospasm, sneezing that is painful, hoarseness to their bark,
noise on exhalation, coughing and wheezing while breathing. Peripherally acting agents can have a latent period of 30
minutes to 72 hours. Major effects do not occur until hours later. If major signs show in less than 4 hours the prognosis is
lower. Shortness of breath from pulmonary edema occurs. As damage progresses, this dyspnea becomes more severe
and coughing develops with a clear foamy sputum. Phosgene patients can lose as much as 1L of serum into their lungs
from protein denaturation.
Choking Agent Tx: Terminate the exposure. No mask for a dog so the animal must be moved from the contaminated
environment. Establishing an airway in an animal that has stridor is important but may require sedation and the use
of a bite block. Airway/trachea may require frequent suction with a squib to keep it clear. Ensure normovolemia and
treat with crystalloid fluids if the animal seems dehydrated. 100% oxygen if needed. Enforce rest. Reserve antibiotics
for confirmed secondary infections when possible. Steroid or albuterol therapy may be necessary for bronchospasm
(albuterol at 0.05mg/kg PO, dexamethasone 0.025mg/kg q24hr PO; so about a 0.5–1mg tablet or prednisolone 1mg/kg
q12hr for up to a week PO, then 0.5mg/kg for another week). Positive airway pressure helps oxygen delivery in the face
of pulmonary edema but can decrease thoracic venous return and contribute to hypotension. Ensure blood pressure
which may require fluid therapy. If a ventilator can be used, set as suggested below. Some BVMs have a PEEP setting.

204 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS