Abstract
Introduction
Hydroxocobalamin, a precursor molecule to vitamin B12, has emerged as the preferred
empiric treatment for patients rescued from enclosed-space fires with concern for
inhalational injury and potential concomitant cyanide toxicity. Limited data exist
on the effects of hydroxocobalamin toxicity, particularly in pediatric patients.
Case report
We report a case of a healthy three-year old girl who was rescued from an apartment
fire and electively intubated by prehospital providers. Due to concern for potential
cyanide toxicity, she received 5 g (373 mg/kg) of intravenous hydroxocobalamin, an
amount equivalent to one standard adult dose but over five times the appropriate weight-adjusted
dose for this 13.4-kilogram child. On hospital arrival, patient was noted to have
chromaturia and diffuse erythroderma without cutaneous burns. She was extubated 4 h
after prehospital intubation and discharged home the following morning in good condition
with persistent erythroderma. Skin color returned to normal within two days.
Discussion
We believe this to be the first reported case of iatrogenic pediatric hydroxocobalamin
overdose for the treatment of suspected cyanide toxicity. Erythroderma and chromaturia
are expected side effects of hydroxocobalamin, even at therapeutic levels. Along with
minor airway burns, the only other finding was a transient and hemodynamically neutral
bradycardia, which began shortly after prehospital intubation. As this bradycardia
occurred prior to hydroxocobalamin administration, more likely culprits include vagal
nerve stimulation from direct laryngoscopy, and sinoatrial muscarinic receptor stimulation
caused by repeated doses of succinylcholine. In all, we were unable to appreciate
any complications due to excess hydroxocobalamin administration.
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Article Info
Publication History
Published online: April 10, 2019
Accepted:
April 9,
2019
Received:
April 6,
2019
Footnotes
☆Previously presented as a poster at 2018 North American Congress of Clinical Toxicology.
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
