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TEMPLATE SOP FOR SAFELY WORKING WITH CYANIDES [Enter text in the highlighted words in italics to include specifics for your laboratory.]Note: Enter your specific cyanide chemical name in any “cyanide” field and click elsewhere. All other “cyanide” fields will be populated with your specific chemical name.Standard Operating Procedures for [cyanide]Cyanide is a fast acting poison that can be lethal at mg doses. When inhaled, ingested or absorbed through the skin or mucous membranes, it can cause symptoms ranging from minor respiratory irritation to severe breathing difficulty, cardiac arrest, convulsions and/or death within minutes. The severity of adverse health effects depends on the properties of the specific cyanide-containing chemical and the exposure concentration. Personnel using these chemicals are required to exercise extreme caution and follow these guidelines when working with cyanides, particularly hydrogen cyanide, potassium cyanide and sodium cyanide. Other cyanide-containing chemicals that require the same or similar precautions include barium, calcium, copper, potassium silver, silver and zinc cyanides and other soluble cyanide salts. Also, organic nitriles of concern include cyanogen, cyanogen halides, and benzyl and ethyl cyanides. Less hazardous cyanides may not require all precautions given below, but the procedures and conditions for use and potential for exposure should be assessed. For example, less hazardous potassium ferricyanide can emit toxic cyanide fumes when heated to decomposition or comes in contact with acids or acid fumes. Always consult the Safety Data Sheet/Material Safety Data Sheet (SDS/MSDS) of cyanide chemicals to assess their hazards and determine safe work practices. 1. Chemicals/Hazards[Obtain specific chemical hazard information from SDS/MSDS.] Chemical name: [XXX]CAS number: [XXX]Routes of exposure: [XXX]How exposure might occur: [XXX]Target organs: [XXX]Signs/symptoms of exposure: [XXX]2. Process[Describe or attach what is being done with [cyanide], including specific laboratory procedures and quantities used.] [ Click here to enter text ] 3. Preparation for UsePurchase the smallest amount of [cyanide] feasible for a specific task, or purchase [cyanide] diluted to the concentration for use.Develop procedures to minimize the potential for any cyanide exposure. Consider obtaining a medical grade oxygen kit from an approved vendor to have on hand for first aid response to potential exposures.Provide hazardous chemical and specific SOP training to personnel working with [cyanide] and any other personnel authorized or required to be in the laboratory or shared space during work with the chemical.Enter [cyanide] into MyChem inventory, the online UW chemical inventory system. Attach SDS/MSDS in the process. Annually review amount of cyanide stored and update MyChem inventory or confirm amount previously recorded.Determine appropriate cleaning and decontamination method(s) for [cyanide]. Many cyanide chemicals are cleaned from surfaces and equipment with a pH 10 buffer solution and then rinsing with a freshly made 10% bleach solution. Ensure supplies for cleaning/decontamination are readily available.Purchase or assemble supplies for a spill cleanup kit for [cyanide]. Ensure the kit is maintained, anticipated users are trained in its use and the kit is readily available in the laboratory.4. Environmental/Ventilation ControlsPerform ALL work with [cyanide] in a certified chemical fume hood or other approved exhausted containment. Test hood to ensure it is functioning properly prior to beginning work (review information in Lab Safety Manual about this). 5. Personal Protective Equipment (PPE)The following PPE will be worn when working with [cyanide]: [Customize list]Disposable nitrile exam gloves are used at all times Two pairs of disposable nitrile exam gloves or one pair of non-disposable nitrile gloves (minimum 10 mil thickness) when working with cyanides that readily absorb through the skin, when cleaning up spills and when handling cyanide-containing liquids.Safety glasses with side shields or , if working with a volatile cyanide, chemical safety gogglesLab coat or equivalent. Wear long pants or long skirt, and fully closed shoes.If splash or exposure to vapors is possible, wear face protection such as a face shield, and an impermeable apron with sleeves.Respiratory protection is usually not needed when all work is conducted in a fume hood. If any procedure may pose an exposure hazard, such as generation of cyanide dust, aerosol or vapor, it should be eliminated or strictly isolated. The only acceptable respirator for protection against hydrogen cyanide is a tight-fitting full face respirator with supplied air. Please contact the EH&S Respiratory Protection Program administrator to discuss respiratory protection or to enroll in the program. Program enrollment includes medical evaluation, training and fit testing for an appropriate respirator. Contact EH&S at 206-616-3777 for information or visit gloves immediately if contaminated, torn, or punctured.6. Special Handling Procedures & Storage RequirementsHANDLINGNever work alone when working with cyanides!Weighing and PrepFor weighing or use, transport [cyanide] from the storage area to the chemical fume hood in a labeled, sealed non-breakable secondary container. Always remove cyanide from its secondary container in a chemical fume hood in order to safely vent any accumulated vapor.Perform all weighing and preparation of [cyanide] solutions over plastic-backed absorbent pads in a chemical fume hood. Dispose of pads immediately upon contamination and after completion of tasks in a bag labeled as [cyanide] hazardous waste.Wear nitrile gloves for all procedures involving preparation and handling of [cyanide]. Wear two pairs of disposable nitrile exam gloves or one pair of non-disposable nitrile gloves (minimum 10 mil thickness) when working with cyanides that readily absorb through the skin, when cleaning up spills and when handling cyanide-containing liquids.Change gloves after each use, or immediately when torn, punctured, or contaminated. Wash hands thoroughly.[Describe how cyanide chemical will be weighed and prepared.] [ Click here to enter text ] UseIf applicable, a sharps container specifically for [cyanide] will be in the immediate vicinity for safe sharps disposal. Avoid use of needles/sharps or use safety sharps that you are experienced with when possible.Place all potentially contaminated disposable items in a separate [cyanide] hazardous waste bag or container before disposal.Non-disposable utensils, glassware, and other surfaces contaminated with cyanide compounds must be decontaminated at the end of the laboratory work session. Complete this inside a fume hood before removing any of the items. Wash all contaminated surfaces with [cleaning solution] or pH 10 buffer solution and rinse with a freshly made 10% bleach solution. When work completed, remove gloves and wash hands with soap and water.STORAGEStore [cyanide] in tightly sealed labeled container in a locked [select container from dropdown] away from water and moisture to prevent interactions that produce toxic hydrogen cyanide gas. Sodium and potassium cyanide can react with water and even humidity to produce hydrogen cyanide gas. Keep [cyanide] safe from theft in a locked room [room #]. Key to the locked container will be held by [enter name(s)].Store [cyanide] in labeled, sealed non-breakable secondary container within the locked container, if potential for disturbance or breakage exists.Store [cyanide] separately from strong acids such as hydrochloric, sulfuric and nitric acid and acid salts as their interaction releases highly flammable and toxic hydrogen cyanide gas.Store [cyanide] away from incompatible chemicals to prevent adverse reactions including formation of hydrogen cyanide gas. These include oxidizing agents (such as perchlorates, peroxides, permanganates, chlorates, nitrates, chlorine, bromine, and fluorine), amines, calcium hydroxide, caustic ammonia, sodium carbonate, iron and magnesium.TRANSPORTTransport [cyanide] in labeled and sealed non-breakable secondary containers.7. Spill and Accident Procedures[Specific cleaning and waste disposal procedures must be determined.]Any [cyanide] spills must be cleaned up immediately by properly protected and trained personnel. All other persons should leave the area. Spill response procedures must be developed based on the chemical and potential spill or release conditions. Clean up spills using contents of the spill kit. Do not attempt to clean up any spill if not trained or comfortable. Since cyanides will react with water to produce toxic hydrogen cyanide gas, never attempt to clean up cyanide spills with plain water. Evacuate the area and call 911 for help. If the spill is out of control, call 911. If a person is injured, exposed or suspected of being exposed to cyanides, call 911 immediately. Follow EXPOSURE PROCEDURES in section 8 below.Small Spills inside a fume hood or approved containmentClose hood sash, cordon off area.Call EH&S (during business hours (M-F/8-5) 206-543-0467, outside business hours 911); tell them that a cyanide spill has occurred and you need advice or assistance. Notify supervisor.Do not attempt to clean up spilled cyanide with plain water since cyanides will react with water to form toxic hydrogen cyanide gas.Personnel must wear a lab coat or smock, safety goggles, and two pairs of disposable nitrile gloves (or one pair of non-disposable nitrile or butyl gloves (minimum 10 mil thickness) or Silver Shield gloves), when cleaning up spills.Liquids: Wipe up spilled liquids with absorbent pads.Solids: Gently cover solid spills with paper towels or absorbent pads wetted with pH 10 buffer solution to avoid raising dust and then wipe up. Clean the spill area thoroughly with pH 10 buffer solution followed by dilute bleach solution.If spill is extensive within the containment, clean all interior surfaces after completion of the spill cleanup as in 7 above. Double bag all waste in plastic bags labeled with the contents and store in fume hood away from incompatible chemicals or procedures. Submit request to EH&S for cyanide hazardous waste pick up.Large Spills inside fume hood or approved containmentClose hood sash, cordon off area.Call EH&S (during business hours (M-F/8-5) 206-543-0467, outside business hours 911); tell them that a cyanide spill has occurred, and that you need help managing the spill. EH&S will contact a spill cleanup contractor. Notify supervisor.Be prepared to provide the following information: Name and phone number of knowledgeable person that can be contacted Name of chemical spilled, concentration and amount spilled, liquid or solid type spillNumber of injured, if any (refer below to EXPOSURE PROCEDURES in case of emergency)Location of spillThis information should also be reported to the Emergency Department (ED) after potential exposure.Any Spill outside of fume hood or approved containment Evacuate all personnel from the laboratory and restrict access. As soon as possible report the spill by notifying EH&S (during business hours (M-F/8-5) 206-543-0467, outside business hours 911); tell them that a cyanide spill has occurred, and you need help managing the spill. EH&S will contact a spill cleanup contractor. Notify supervisor.Be prepared to provide the following information: Name and phone number of knowledgeable person that can be contacted Name of chemical spilled, concentration and amount spilled, liquid or solid type spillNumber of injured, if any (refer below to EXPOSURE PROCEDURES in case of emergency)Location of spillThis information should also be reported to the Emergency Department (ED) after potential exposure.Any spill incident requires the involved person or supervisor to complete and submit the Online Accident Reporting System (OARS) form to EH&S within 24 hours (8 hours if serious injury or hospitalization).For questions on spill cleanup, contact EH&S spill consultants at 206-543-0467.8. EXPOSURE PROCEDURESIn Case of EmergencyIf cyanide exposure is suspected call 911 immediately and tell them this is a possible cyanide poisoning. Before assisting affected person, ensure that assisting does not cause cyanide exposure to the responder. Do not contact the affected person’s contaminated clothing or skin without PPE and do not give mouth-to-mouth resuscitation.Treat all exposures (skin, inhalation, ingestion) seriously. Do not rely on odor threshold as 20-60% of people cannot detect the “bitter almond” odor of hydrogen cyanide gas.Symptoms of acute exposure are:Weakness, difficulty breathingHeadache, confusion, dizziness, vertigoNausea, vomitingSkin becomes pink/cherry red from cyanide-hemoglobin reactionContinued exposure can cause coma, pulmonary edema, cardiac arrestProvide First Aid Immediately For inhalation exposure, without contaminating yourself, move the individual out of contaminated area to fresh air while awaiting emergency responders. Do not give mouth-to-mouth or mouth-to-nose resuscitation, as this may cause cyanide exposure to the rescuer.For sharps injury (needlestick or subcutaneous exposure), scrub exposed area thoroughly for 15 minutes using warm water and sudsing soap.For skin exposure, use the nearest safety shower for 15 minutes. Stay under the shower and remove clothing. Use a clean lab coat or spare clothing for cover-up.For eye exposure, use the eye wash for 15 minutes while holding eyelids open.Get Help Call 911 or go to nearest Emergency Department (ED). Inform them this is a possible cyanide poisoning and that cyanide antidote should be available. Give details of exposure:ChemicalDoseRoute of exposureTime since exposureBring to the ED the SDS/MSDS and this SOP with the attached CDC Medical Guidelines for Cyanides Exposure.Notify your supervisor as soon as possible for assistance.Secure area before leaving. Lock doors and indicate spill if needed.Report Incident to Environmental Health & SafetyNotify EH&S immediately after providing first aid and/or getting help.During business hours (M-F/8-5) call 206-543-7262.Outside business hours call 206-685-UWPD (8973) to be routed to EH&S staff on call.For all incidents and near misses, the involved person or supervisor completes and submits the UW Online Accident Reporting System (OARS) form to EH&S within 24 hours (8 hours if serious injury or hospitalization).9. Waste Disposal and CleaningContact EH&S Environmental Programs at 206-616-5835 for assistance with hazardous chemical waste disposal procedures.Work space surfaces must be wiped down after completion of tasks with [cleaning solution]. Absorbent pads will be replaced after completion of tasks or immediately if contaminated.Note that many cyanide-containing chemicals are Environmental Protection Agency (EPA) P-Listed (acutely toxic)* chemicals, which have stringent requirements for waste disposal as listed below. Cyanide chemicals determined to be less hazardous should be handled and disposed of using procedures given in the EH&S Lab Safety Manual.Unused and waste P-listed cyanide solid and solutions must be sealed in labeled chemically compatible sturdy containers (no more than one quart in volume) for pickup as hazardous cyanide waste by EH&S. The bottles a P-listed cyanide was received in, even when empty, must be managed and collected as hazardous cyanide waste. This also includes empty vials, syringes, pipette tips, and other containers if the cyanide-containing chemical was the sole active ingredient in the container.Used and potentially contaminated absorbent pads, PPE, etc. will be placed in a labeled hazardous chemical waste bag specifically for the P-listed cyanide. Submit request to EH&S for pickup.Used sharps will be placed in sharps containers specifically labeled as containing P-listed cyanide-containing chemical. Submit request to EH&S for pickup.Keep cyanide waste materials in closed and labeled dedicated bags and containers within a fume hood away from incompatible chemicals or procedures before EH&S pickup.For chemical waste pickup: Complete either an Online Chemical Waste Collection Request or a Chemical Waste Collection Request Form , fax or mail the form to: chmwaste@uw.edu, FAX to 206-685-2915, or mail to Box 354110.*barium cyanide, calcium cyanide, copper cyanide, cyanides (soluble cyanide salts not otherwise specified), cyanogen, cyanogen chloride, ethyl cyanide, hydrogen cyanide, nickel cyanide, potassium cyanide, potassium silver cyanide, silver cyanide, sodium cyanide, zinc cyanide10. Special Precautions for Use of [cyanide] in Animals(if applicable)Use of [cyanide] in animals will be documented and approved by IACUC.[Give detailed procedures for safely completing tasks and any special disposal requirements.] [ Click here to enter text ] Particularly hazardoussubstance involved?X YES:Blocks #11 to #13 are Mandatory NO:Blocks #11 to #13 are Optional.11. Approval RequiredAll staff working with [cyanide] or having access to it must be trained on this SOP prior to starting work. They must also review the [cyanide] SDS/MSDS, and it must be readily available in the laboratory. All training must be documented and maintained by the PI or their designee.12. DecontaminationAll surfaces and non-disposable equipment must be decontaminated with [cleaning solution] or washed with pH 10 buffer solution and rinsed with 10% bleach solution. 13. Designated AreasAll work with [cyanide] must be done in a designated laboratory and chemical fume hood. This work will be conducted in [room #].The [cyanide] chemical will be stored in [room #] in a locked container.Name:(PI or Lab Manager)Title:Signature: Date:The attached documents are for medical personnel caring for cyanide-exposed individuals: OSHA Standard Interpretations for cyanide antidotes (for standards 1910.126(e); 1910.151; 1910.151(a); 1910.1000); andCDC Medical Guidelines for Cyanide Exposure with strike-through for any references to amyl nitrate**Per the OSHA Standard Interpretations for cyanide antidotes, amyl nitrite is no longer available in cyanide antidote kits in the U.S., and is no longer an acceptable initial therapeutic response. The cyanide antidotes currently available are hydroxocobalamin, sodium nitrite, and sodium thiosulfate, are given via intravenous (IV) infusion, and therefore can only be administered by qualified healthcare professionals.Please provide this entire document with attachments to professional first aid responders and the emergency department.FOR MEDICAL PERSONNEL:From OSHA webpage: March 31, 2020MEMORANDUM FORREGIONAL ADMINISTRATORSSTATE PLAN DESIGNEESTHROUGH:LOREN SWEATTPrincipal Deputy Assistant SecretaryFROM:LEE ANNE JILLINGS, Acting DirectorDirectorate of Technical Support and Emergency ManagementPATRICK J. KAPUST, Acting DirectorDirectorate of Enforcement ProgramsSUBJECT:Cyanide AntidotesThis memorandum serves as new guidance to address outdated information provided in OSHA’s archived memo dated?May 17, 1988, from the Office of Occupational Medicine, and entitled “Cyanide Antidote Kits.” ?The prior memo stated in part, “Amyl Nitrite continues to require a physician’s prescription and the administration of this drug in an emergency situation by the designated first aide responder is the medically accepted initial response.? According to current literature, hydroxy cobalamine has had limited use as an alternative intravenous medication to the widely accepted sodium nitrite protocol.”1This memo provides the following updated information regarding cyanide antidotes:Amyl nitrite (which was given via inhalation) is no longer available in cyanide antidote kits in the U.S., and is no longer an acceptable initial therapeutic response.Currently, the available cyanide antidotes are hydroxocobalamin, sodium nitrite, and sodium thiosulfate.The three available antidotes are given via intravenous (IV) infusion and, therefore, can only be administered by qualified healthcare professionals.RationaleAntidote kits containing inhaled amyl nitrite are no longer commercially available.2? The U.S. Food and Drug Administration (FDA) stated, as of September 2018, that the only products approved for cyanide poisoning are the following:? Cyanokit (hydroxocobalamin injection), Nithiodote (sodium nitrite and sodium thiosulfate for intravenous infusion), sodium nitrite injection, and sodium thiosulfate injection.3? In 2018, an expert consensus panel determined that hydroxocobalamin is the preferred antidote, but sodium nitrite and sodium thiosulfate are also acceptable.2? In light of the experts’ recommendation to use hydroxocobalamin, and the absence of amyl nitrite on the FDA list of approved cyanide antidotes,3?amyl nitrite is no longer an acceptable antidote option.Employers that offer antidote therapy for cyanide poisoning should provide one of the FDA-approved products.? Ideally, cyanide antidotes should be given soon after exposure to unconscious victims with known or strongly suspected cyanide poisoning.2,4,5? Because all currently FDA-approved cyanide antidotes are IV infusions, they should only be given by healthcare professionals whose scope of practice includes administration of IV drugs.? Employers should heed all aspects of the antidote’s “Indications and Usage” labeling.? In addition to specific antidotes, cyanide poisoning requires other therapeutic interventions. Depending on the scenario, victims might require cardiopulmonary resuscitation, supplemental 100% oxygen, decontamination, and other supportive care.4,5? Most cyanide exposures will result in activation of emergency medical services (EMS).? EMS providers could assist with administration of antidotes or non-specific therapies.? Therefore, when there is a foreseeable risk of cyanide exposure, employers should communicate with their local EMS agency to plan for exposure controls, hazard recognition, training, and treatment availability.Inspection guidanceDue to the acute and lethal hazards presented by cyanide poisoning, an employer covered under OSHA’s standard, Medical Services and First Aid, 29 CFR 1910.151(a), with a workplace that has a foreseeable risk of cyanide exposure, must consult with a physician or other licensed health care professional (PLHCP).? This consultation shall ensure that emergency medical services, including those equipped with effective cyanide antidotes, are readily available in the event of an acute cyanide overexposure in the workplace.? The absence of such consultation is enforceable as a serious violation.Specifically, this medical consultation should address workplace-specific considerations, such as appropriate storage and replenishment of medical supplies (e.g., FDA-approved antidote drugs, intravenous supplies), and pre-placement of emergency medical equipment and first-aid supplies (e.g., portable oxygen tanks, automated external defibrillators or AEDs).? Where appropriate, consultation shall also address on-site staffing, training, and licensing requirements of first aid and medical responders; wait times for EMS/ambulance arrival; when and how intravenous drugs can be administered; worker susceptibility, etc.? Compliance officers shall bring any deficiencies in the availability of medical supplies or personnel to the attention of their supervisor and, as needed, to their Regional Office for further evaluation.Additionally, for workplaces with potential cyanide exposures, other applicable OSHA standards may include, but are not limited to:? 29 CFR 1910 Subpart E, Exit Routes and Emergency Planning; Subpart H, Hazardous Materials – Dipping and Coating Operations; Subpart I, Personal Protective Equipment; 29 CFR 1910.94 Ventilation; and 29 CFR 1910.1200, Hazard Communication.If you have any questions, please contact Dr. Michael Hodgson,?hodgson.michael@,(202) 693-1768, with the Office of Occupational Medicine and Nursing, Directorate of Technical Support and Emergency Management, or Dr. Dionne Williams,?williams.dionne@, (202) 693-2140, with the Directorate of Enforcement Programs.References1. Archived OSHA memorandum “Cyanide Antidote Kits,” dated May 17, 1988. Available at:?. Dart RC, Goldfrank LR, Erstad BL, et al. Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Annals of Emergency Medicine 2018;71(3):314-325. Available at:?(17)30657-1/fulltext3. U.S. Food and Drug Administration (FDA). Products approved for chemical emergencies: products for cyanide poisoning. Updated September 27, 2018. Available at:?. Agency for Toxic Substances & Disease Registry (ATSDR). Medical management guidelines for hydrogen cyanide (HCN). Available at:?. U.S. Department of Health & Human Services, Chemical Hazards Emergency Medical Management (CHEMM). Hydrogen cyanide – emergency department/hospital management. Available at:? U.S. Centers for Disease Control and Prevention (CDC) published the following guidelines to provide information and guidance to professional medical first responders and emergency department medical staff in responding to patients with suspected cyanide poisoning.CDC Medical Guidelines for Cyanide Exposure(hydrogen cyanide, potassium cyanide, sodium cyanide, cyanogen chloride)GENERAL INFORMATION: Careful observation, supplemental oxygen, and supportive care may be sufficient therapy for the patient/victim who does not exhibit physical findings of cyanide toxicity. For the patient/victim exhibiting physical findings of cyanide toxicity, initial treatment consists of administration of antidotes under a physician's direction, respiratory and circulatory support (oxygen and IV fluids), correction of chemical imbalances in the blood, and seizure control. Speed is critical. Avoid mouth-to-mouth resuscitation regardless of route of exposure. Avoid contact with vomitus, which may off-gas hydrogen cyanide. ANTIDOTESPatients who have signs or symptoms of significant systemic toxicity should be evaluated for antidotal treatment. When possible, treatment with cyanide antidotes should be given under medical supervision to unconscious victims who have known or strongly suspected cyanide poisoning. There are currently two cyanide antidotal kits approved by the U.S. FDA. Use either:Cyanide Antidotal Kit that includes amyl nitrite perles and intravenous infusions of sodium nitrite and sodium thiosulfate; orCyanokit that employs intravenous infusion of hydroxocobalamin (FDA 2006; HSDB 2007).CYANIDE ANITIDOTAL KIT: Amyl nitrite, sodium nitrite, and sodium thiosulfate are antidotes for cyanide toxicity; however, amyl nitrite and sodium nitrite should not be administered to patient/victims suffering from smoke inhalation, are pregnant or have preexisting hypotension. In these cases, only administer sodium thiosulfate or use the alternative Cyanokit antidote. The described administration of nitrites is based on a patient having normal hemoglobin levels. Below normal hemoglobin levels require titration of nitrites. For mild to moderate physical findings such as nausea, vomiting, palpitations, confusion, anxiety, dizziness (vertigo), and/or abnormally fast or deep respiration (hyperventilation):Observe the patient/victim and administer 50 mL of a 25% solution (12.5 g) of sodium thiosulfate intravenously over a period of 10 minutes.For severe physical findings such as coma; cessation of breathing (apnea); seizures; slowness of the heart rate, usually to fewer than 60 beats per minute (bradycardia); abnormally low blood pressure (hypotension); bluish skin coloring due to abnormally low levels of oxygen in the blood (cyanosis); irregular heart beat (dysrhythmias); and/or accumulation of fluid in the lungs (pulmonary edema):Until sodium nitrite becomes available, break one ampule of amyl nitrite into a gauze pad. Out of every minute, hold the cloth containing amyl nitrite held under the patient’s nose, placed under the lip of a facemask, or over the Ambu-valve intake. The patient should inhale for 30 seconds, and then remove it for 30 seconds, until sodium nitrite can be administered. A new ampule of amyl nitrite should be broken into a cloth every 3 minutes. If the patient has not responded to oxygen and amyl nitrite treatment, infuse sodium nitrite intravenously as soon as possible. Discontinue use of amyl nitrite when sodium nitrite becomes available. Administer 10 mL of a 3% solution (300 mg) infused over absolutely no less than 5 minutes. Monitor blood pressure during sodium nitrite administration, and slow the rate of infusion if hypotension develops (HSDB 2007).Next, administer 50 mL of a 25% solution (12.5 g) of sodium thiosulfate intravenously over a period of 10 to 20 minutes. If physical findings persist for 30 minutes after antidote administration, sodium nitrite and sodium thiosulfate may be readministered at half their original respective doses. However, methemoglobin levels should be monitored and not allowed to exceed 40%.CYANOKIT (hydroxocobalamin): Infuse hydroxocobalamin (5 g) intravenously over 15 minutes. Depending on the severity of poisoning and the clinical response, a second dose of 5 g may be administered over 15 minutes to 2 hours (based on patient condition). The recommended diluent is 0.9% sodium chloride. Some drugs are incompatible with hydroxocobalamin, in which case, a separate intravenous line may be necessary ( 2007).RESPONSE TO SPECIFIC ROUTES OF EXPOSUREEYE:Immediately remove the patient/victim from the source of exposure.Immediately wash eyes with large amounts of tepid water for at least 15 minutes. Monitor the patient/victim for signs of whole-body (systemic) effects.If signs of whole-body (systemic) poisoning appear, see the Inhalation section for treatment recommendations.Seek medical attention immediately.INGESTION:Immediately remove the patient/victim from the source of exposure. Establish secure large-bore IV access.Ensure that the patient/victim has an unobstructed airway.Do not induce vomiting (emesis).Immediately administer 100% oxygen.Prepare a cyanide antidote kit, for use under a physician’s direction, for symptomatic patient/victims. See the Antidote section for antidote administration procedures.Treat seizures with benzodiazepines.Seek medical attention immediately.INHALATION:Immediately remove the patient/victim from the source of exposure.Evaluate respiratory function and pulse.Ensure that the patient/victim has an unobstructed airway.Immediately administer 100% oxygen.Assist ventilation as required.If breathing has ceased (apnea), provide artificial respiration with an AmbuBag or similar.Establish secure large-bore intravenous (IV) access.Prepare a cyanide antidote kit, for use under a physician’s direction, for symptomatic patient/victims. See the Antidote section for antidote administration procedures.Monitor for respiratory distress.Seek medical attention immediately.SKIN:Immediately remove the patient/victim from the source of exposure.Remove and double-bag contaminated clothing. Flush exposed skin and hair with copious amounts of water for at least 15 min. Wash with soap and rinse thoroughly with water. For symptomatic patients, provide treatment with 100% oxygen and specific antidotes as needed. Treatment should be given simultaneously with decontamination procedures.Monitor the patient/victim for signs of whole-body (systemic) effects.If signs of whole-body (systemic) poisoning appear, see the Inhalation section for treatment recommendations.Seek medical attention immediately.See ATSDR Medical Management Guidelines for Acute Chemical Exposures, Hydrogen Cyanide, , for detailed recommendations. Last update: 5/8/14.[Laboratory Name]Documentation of TrainingStandard Operating Procedure for [cyanide]NameSOP Training DateSignatureClick here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date.Click here to enter name.Click here to enter date. ................
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