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Initiate this protocol if the patient has signs and symptoms consistent with cyanide poisoning in a setting where cyanide exposure is probable, even if cyanide poisoning cannot be definitively proved.

1. Use PPE to prevent exposure to cyanide.

2. Remove to a non-contaminated environment.

3. Rapidly decontaminate patient to prevent further absorption of cyanide.

4. Administer high flow oxygen by non-rebreather mask.

5. If patient is not ventilating adequately, assist respirations with bag-valve-mask.

6. If the patient is breathing, crush an amyl nitrite inhalant and permit patient to inhale vapors for 15 to 30 seconds while intravenous access is being established. Work simultaneously to establish IV. May be repeated every 15 seconds. Pediatric dose is the same. Use the smallest effective dose.

7. Administer 0.2 ml/kg of sodium nitrite 3% solution IV over 3-5 minutes, not to exceed 10 ml. Discontinue amyl nitrite inhalations

8. Administer adults sodium thiosulfate 12.5 grams (50 ml of 25% solution) IV over 1-2 minutes. For children, give 0.25mg/kg up to 12.5 grams over 3-5 minutes.

9. Assess vital signs. If hypotensive, elevate feet and administer fluid challenge with normal saline. Cardiac monitor, blood pressure monitor, pulse oximeter.

10. If patient does not improve, or if signs and symptoms of cyanide poisoning recur, or if cyanosis develops, CONTACT MEDICAL CONTROL.

11. If cardiac arrest occurs, begin CPR and complete cyanide antidote protocol before initiating cardiac resuscitation protocols. Patient will have metabolic acidosis. Administer Sodium Bicarbonate 1 mEq/kg as initial dose. CONTACT MEDICAL CONTROL.