Impact of Protocol Development on Hydroxocobalamin Use for Smoke Inhalation Injury with Suspected Cyanide Toxicity: A...

Area of Science:

• Emergency Medicine
• Toxicology
• Public Health

Background:

• Structure fires annually cause significant civilian deaths in the US.
• Combustion byproducts include toxic hydrogen cyanide gas.
• Empirical use of hydroxocobalamin for cyanide toxicity lacks clear guidelines, leading to potential overuse.

Purpose of the Study:

• Evaluate hydroxocobalamin protocol compliance for inhaled cyanide toxicity.
• Compare adherence pre- and post-implementation of specific criteria and a smart order set.

Main Methods:

• Retrospective review of hydroxocobalamin use in patients with inhalation injury.
• Comparison of pre-protocol (2022) and post-protocol (2023-2024) groups.
• Defined criteria for hydroxocobalamin administration based on exposure, injury timing, cardiac arrest, GCS, lactate, and carboxyhemoglobin levels.

Main Results:

• 127 patients met inclusion criteria (62 pre, 65 post).
• Appropriate hydroxocobalamin utilization increased from 29% to 48% post-protocol.
• Delayed administration (2+ hours post-exposure) was the primary reason for deviation in both groups.
• No significant differences in mortality or length of stay were observed.

Conclusions:

• Identifying patients with risk factors for cyanide toxicity from inhalation injury is crucial.
• Established criteria promote judicious stewardship of hydroxocobalamin.