In fact, the scientific literature recommends pediatric dosing based on monitoring hemoglobin levels. While excessive sodium nitrite can cause methemoglobinemia, it should be noted that in the 70-year history of using the kit, the only reported fatality of such toxicity from using the kit involved a child without serious cyanide poisoning who was given two adult doses of sodium nitrite ( Berlin, 1970 Hall and Rumack, 1986).
Taylor Pharmaceuticals, the manufacturer of the kit, recommends the dose for children of sodium nitrite to be 6–8 mL/m 2 (approximately 0.2 mL/kg body weight), but not to exceed an adult dose of 10 mL of a 3% solution (approximately 300 mg).
Continuous use of amyl nitrite may prevent adequate oxygenation. This should be reapplied using this interrupted schedule until sodium nitrite can be administered. Once an ampule of amyl nitrite has been broken one at a time into a handkerchief, the contents should be held in front of the patient’s mouth for 15 s, followed by 15 s of rest. Treatment of children affected with cyanide intoxication must be individualized based upon their body weight and hemoglobin concentration. The doses given to an adult can potentially cause a fatal methemoglobinemia in children or may cause profound hypotension. Therapy with nitrites is not innocuous, since methemoglobin cannot transport oxygen in the blood. Once bound with the cyanide, the methemoglobin becomes cyanmethemoglobin ( Anon, 1998). Cyanide is more strongly drawn to methemoglobin than to the cytochrome oxidase of cells, effectively pulling the cyanide off the cells and onto the methemoglobin ( Berlin, 1970 Baskin and Brewer, 1997). This antidote converts a portion of the hemoglobin’s iron from ferrous iron to ferric iron, converting the hemoglobin into methemoglobin. The US standard cyanide antidote kit uses a small inhaled dose of amyl nitrite followed by IV sodium nitrite and sodium thiosulfate ( Anon, 1998 Rotenberg, 2003a).
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