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Sunday, April 20, 2014

Part 2: Does Cyanokit save lives in cardiac arrest?

In the last post I reviewed some key facts about hydroxocobalamin (HCB), otherwise known by its brand name Cyanokit. However, paramedics and firefighters aren't really concerned with the animal studies - they want to know if it saves human lives! 

And according to some flashy headlines, many people believe this stuff works when nothing else can.


Source
Source
Source
But these are news reports and press releases - what does the medical evidence show? 


Does HCB help in cardiac arrest due to smoke?
This is the tough hurdle for studying any toxicologic antidote, and it's especially hard to do research in this area. The events are rare, and it's usually an emergency when these poisoning occur. For these reasons, and more, there have only been a few studies of HCB in humans.

Four studies have looked at the use of HCB in smoke-exposed patients. Interestingly, 3 of them were done in France, mostly in Paris.


Just for fun, Google "Paris" and "burning."

Study #1 - All smoke exposure patients who got HCB  

The authors of the first study looked at all the patients treated with HCB over an 8-year period  for "suspected cyanide poisoning" after a smoke inhalation, usually from a house fire. It's important to understand that there was no comparison group so it is impossible to know whether the drug helped, hurt, or did nothing.

With that in mind, all 101 patients got HCB, and all were from residential house fires; about 1/3 of those were in cardiac arrest. Forty two patients died, 30 survived, and the status of 29 patients was "unknown.



How about patients found in cardiac arrest? Of the 38 patients who where found in arrest, 21 of those had prehospital ROSC - pretty encouraging. Unfortunately,  the majority of those (19/21) subsequently died in the ICU.

This might be encouraging if we were givne some data about those 2 out of 38 patients who survived. For instance, did they get the HCB before, during, or after their cardiac arrest? Unfortunately, there are no further details

Study #2 - All cyanide exposures who got HCB

Just like the study above, the authors of study #2 included patients with smoke inhalation or cyanide ingestion who were treated with HCB by EMS. Since this was written by the same authors as study #1 above,  and covers mostly the same period (1995-2008), it is likely that many of these patients overlap with those in the prior study.
Out of the 161 patients studied, 61 were found in cardiac arrest. Most of these died in the field, or ended up dying in the hospital, but 5 patients lived after getting HCB from EMS!



 
That's an 8% save rate, which seems very promising, but the authors note that most of these "saves" didn't actually get HCB before they had ROSC. As they point out (my emphasis):
"Among the 61 patients in [cardiac] arrest, 5 survived without sequelae and, in particular, without neurological sequelae. Four of the 5 patients were ... discovered in cardiac arrest by the fire brigade, and spontaneous cardiac activity was obtained after cardiac massage and oxygen therapy. ...
[H]ydroxocobalamin was not responsible for the recovery of spontaneous cardiac activity in these patients."
I'll point out that the 5th cardiac arrest survivor had his age only listed as "adult," suggesting that the EMS records were incomplete, at the least... 


Study #3 - All smoke exposures, who got HCB, and who made it alive to the ICU
The last study adopted a slightly different approach. The authors performed a retrospective "observational case series" of all of the patients who who had smoke exposure, received HCB in the field, and were subsequently admitted to the ICU

A total of 69 patients were enrolled. Of these, 15 patients had been in cardiac arrest when EMS found them. Of these 15 patients, only 2 survived.



Hey, 2/15 is a 13% save rate, which might be really promising. Or might not be - we can't tell from the study design.

Study #4 - All smoke exposure patients who got HCB - in Texas! 
You might not have thought that Paris and Houston would have a lot in common!

You can skip Googling "Paris" and "Houston"
As it turns out, both Parisians and Texans have been using HCB for years, and a just-published abstract describes the experience of the FD in Houston. Unfortunately, the study wasn't "Texas-sized," and was actually smaller than those done in Paris.

Like the French studies, the Houston authors looked retrospectively at all the patients who had received HCB for "possible cyanide poisoning." Over a period of 4 years, 22 patients got the drug. Half of those were found in cardiac arrest, and 8/11 had ROSC "after administration of HCB."

So, awesome, right? Unlike study #2 above, the patients in cardiac arrest actually got HCB before ROSC, not after. Is this proof that HCB, given in arrest, can produce ROSC rates in almost 75% of cases? 

 Limitations of these "case series"studies
Unfortunately, we still can't say.  All of these studies were basically case series. It is very low-quality evidence, ranking just above expert opinion. You can think of such a study design as just a fancy doctor phrase meaning "a bunch of cool stories."




Why? Because there is no comparison group in any of them. Since the drug was never actually tested against another drug, let alone a placebo, we don't know if HCB helped, or did nothing

Heck, for all we know, it may have even hurt patients. We just don't know.

 So, what can we do with this data?
By itself, not much. HCB is a new therapy, with potential, but no solid human evidence to support when we should use it. Of course, we don't always wait for perfect evidence to come along before using drugs and therapies.

With that in mind, what should you and your teammates do the next time FD drags a patient in cardiac arrest out of a fire? Or what if one of your firefighter teammates collapses next to you during a fire?

The next post will offer some suggestions, based on better evidence, of techniques and therapies that have been shown to lives.

51 comments:

  1. Brooks,

    I am in the process of writing a more detailed response that I plan to post tomorrow. In the meantime, my answer is yes. I would administer the Cyanokit to a patient in cardiac arrest that has been removed from a burning building. I would also administer it to a patient that is not in cardiac arrest but 1) is presenting with signs of cyanide toxicity in conjunction and 2) has a lactate greater than 6mmol.

    As for a firefighter, this is a different story. If they collapse during a fire, I don't presume the etiology is from cyanide toxicity. Traditional therapies here. If they are found with either a broken mask or not wearing their mask at all, I would then add it to their treatment.

    Regardless, more to follow.

    -Bobby

    ReplyDelete
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  2. I'll await your longer response! Thanks for reading.

    ReplyDelete
  3. My post is too long...and the footnotes got all messed up in the copy/paste process. Email instead?

    ReplyDelete
    Replies
    1. Brooks.walsh_at_gmail. Looking forward to this mega-response!

      Delete
  4. WIth such goodies as acrolein, cyanide, phosgene and others, both as gasses/vapors and adsorbed onto micro-particles of soot (which reach alveoli and are phagocytized) even in "common" household fires, this should be studied properly. My respects to the French, but they tend to announce too early. (mycrofft)

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  30. I was infected with genital herpes in 2017 and I have been on the quest for a cure since then. October last year when I almost gave up, I came across a post on the internet where I copied the email of  a man named Dr ogbekhilu who provides herbal solutions to diseases. i contacted him and got to an agreement with him and he sent me herbal remedy through the united parcel service alongside instruction on how to use it. To my greatest surprise, I got healed after 18days of using the remedy as assured by the doctor.I decided to share this because I know that there are lots of people out there that need help. contact the doctor via his website https://drogbekhiluherbalhome.simdif.com Contact him for remedy for infection like{1}HIV And AIDS{2}Diabetes{3}Epilepsy{4} Blood Cancer{5} HPV{6} ALS{7}herpes{8}kidney failure
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  31. I was infected with genital herpes in 2017 and I have been on the quest for a cure since then. October last year when I almost gave up, I came across a post on the internet where I copied the email of  a man named Dr ogbekhilu who provides herbal solutions to diseases. i contacted him and got to an agreement with him and he sent me herbal remedy through the united parcel service alongside instruction on how to use it. To my greatest surprise, I got healed after 18days of using the remedy as assured by the doctor.I decided to share this because I know that there are lots of people out there that need help. contact the doctor via his website https://drogbekhiluherbalhome.simdif.com Contact him for remedy for infection like{1}HIV And AIDS{2}Diabetes{3}Epilepsy{4} Blood Cancer{5} HPV{6} ALS{7}herpes{8}kidney failure
    whatsapp contact: +2348102460821

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  33. I want to use this medium to thank Dr Noah, you all should thank him for me. I started having some symptoms, warts started coming in so I went to see my doctor. He carried the test and he said I have (Herpes) so went to another hospital for another test. My doctor prescribed some tubes  and cream which I started using, I use it for a while and I couldn't trace the infection and after a while it came back so I had no choice than to do research on some natural remedies there I saw a post about Dr Noah powerful herbs, I contacted him and purchase the medicine from him which I used for 2 weeks. On the 10th days of using it I couldn't have any trace of if I was not amazed hoping it will come back so that lead to my doctor for confirmation to my greatest surprise the result comes out negative, I was still a bit shocked I want for a month and still no trace then I called Dr Noah to appreciate his work in my life and I promise not to keep it to myself.
    Here's his basic information. Go get in touch with him: dr.noahmedicalcenter@gmail.com, call +1 310 982-4670 and do get your healing.Website https://noahmedicalcentre.webs.com/

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  34. If getting herpes cure was that easy then why do people still suffer from herpes? I was diagnosed of herpes back in 2014 and i was also told it has no cure,I have been leaving with it since then, but i kept praying and doing everything possible to get cured, so i never stop doing research about finding a cure,I came across testimonies about people getting cured through herbal medication and i have always believe in herbs and its medical properties, after doing so many research about it i found DRASHAOSEMUDIAMEN and I discovered he was a professional in herbal medication and he has also helped many people,I contacted him through his mail: DRASHAOSEMUDIAMEN@GMAIL. COM, and +2347052021645 we talked on phone and i confirmed he was genuine,I did all what he told me to do, i received the medicine,use it as he prescribed,and glory be to God almighty i am completely cured, i went back to my doctor to confirm it.do not be deceived THERE IS A CURE FOR HERPES. He is also good at saving you from any kind of diseases like Herpes. HIV/aids. Gonorrhea. Cardiac problem. cold sore. Hpv cure. Cancer. Watering sperm. Womb fertilization. Penis erection. Witch craft attack. S T D diseases. Internal heat Rashes. Fibroid. Low sperm count. Dairy. long sickness. I promise I will always testify for your good work. drashaosemudiamen@gmail. com or whatsapp +2347052021645 GOOD LUCK.  

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  35. I was cured of HIV with the use of natural herbs. My name is Alandre and I'm from Texas. I love herbs so much. Most times, injection and drugs are just a waste of time. I was cured, I suffered from HIV for 13 years but with the help of Dr. Mark herbal medicine, I was cured within a few weeks of drinking the herbs he sent to me through courier delivery service. This same doctor also cured my Aunty from herpes, as soon as I heard she had herpes, I quickly refer her to Dr.Mark and she was cured too after drinking his herbs.I have referred a lot of people to Dr. Mark and they were all cured from their various illness. Have you taken herbs before?. You have spent so much money on drugs,injections,surgeries etc and yet you have no good result to show for it. Contact Dr. Mark now, he is a herbalist doctor, Dr. Mark has herbs that cures Hiv, Herpes, diabetics, asthma, hepatitis, STD, cancer, chronic, etc. Contact Dr Mark through his Email address on: blessedlovetemple@gmail.com Please share the good news to other people once you are cured

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  36. I am very happy today to share this amazing testimony on how Dr. AFRID the herbal doctor was able to cure me from my Herpes Virus with his herbal medicine. I have been a herpes patient for almost 8 months now and have tried different methods of treatment to ensure that I am cured of this terrible disease, but none worked for me, so I had to leave everything to God to handle as I was a Christian who had faith that one day God would intervene in my life, yet I felt so sad and desperate as I was losing almost everaything due to my illness, A few months ago while I was surfing the internet I saw different recommendation about Dr AFRID on how he have been using his herbal Medicine to treat and cure people, these people advice we contact Dr. AFRID for any problem that would help immediately, I contacted Dr AFRID and I told him how I got his contact and also about my disease, after some time Dr. AFRID told me to have faith that he would prepare for me a medication of herbal herbs, he told me I would take this medicine for a few weeks and also asked my home for home address so as possible for him to submit the drug for me, so my good friends after all the process and everything Dr AFRID actually sent me the medicine, I took it as I was directed by Dr. AFRID, after a few weeks passed, while on Dr. AFRID medication I began to experience changes in my body, I had to call my doctor at the hospital for some blood test, after test my hospital doctor told me that I was no longer with the herpes virus and my blood is pretty good, I can not even believe this, Friends well today i am Herpes Free and i want everyone to know that there is a cure for herpes for those who will contact Dr AFRID after reading my testimony, you can kindly contact Dr. AFRID in (DRAFRIDHERBALHOME@GMAIL.C OM) or whatsApp him +2349057260738, God bless you all  

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  37. I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!

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  38. I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!

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  39. I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!






    I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!





    I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!

    ReplyDelete
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