Cyanokit 到院前配置推動

01 / Context

My contribution centres on bringing international evidence and exchange experience into local discussion and training. The 2024 US visit was a team exchange. Drug placement, protocols and clinical decisions are responsibilities of the fire service and its medical direction system.

02 / Field problem

Smoke from a structure fire is not a single toxin. Beyond the well-known carbon monoxide, modern buildings and furniture rely heavily on synthetic materials — carpets, upholstery, PVC, polyurethane foam — which release hydrogen cyanide when burned. This is well documented in international emergency medicine and EMS literature as a combined occupational and environmental exposure for firefighters and the public.

Clinically, high-flow oxygen handles CO but does nothing for cyanide. Cyanide blocks cytochrome c oxidase, so even with adequate blood oxygen the cells cannot use it — leading to metabolic acidosis, altered consciousness, and cardiac arrest. If the prehospital toolkit is limited to oxygen, it is incomplete for combined CO + CN exposures.

03 / Evidence

Hydroxocobalamin (Cyanokit)

Hydroxocobalamin's cobalt(III) center binds cyanide directly to form non-toxic cyanocobalamin, excreted renally, restoring cellular respiration rapidly. Compared to the traditional Cyanide kit (sodium nitrite + sodium thiosulfate), it has a markedly better safety profile in the prehospital environment.

AHA 2025 recommendations

The 2025 American Heart Association update "Part 10: Adult and Pediatric Special Circumstances of Resuscitation" states:

• For adult life-threatening cyanide poisoning, hydroxocobalamin should be administered immediately (Class 1, LOE C-LD).
• If hydroxocobalamin is unavailable, sodium nitrite + sodium thiosulfate may be used (Class 1, LOE C-LD).
• For combined CO + CN exposure (e.g., residential fires) without hydroxocobalamin, sodium thiosulfate alone may be considered (Class 2a, LOE C-EO).
• For life-threatening or highly suspected cyanide poisoning, do not wait for laboratory confirmation; treat early based on clinical findings, exposure risk, and medical direction.
• Pediatric guidance follows the same principles (Class 1, LOE C-EO).

The operative principle: time is life, particularly in enclosed-space fire smoke exposure.

04 / Intervention

If this drug stays in the hospital pharmacy, the time between collapse on scene and access to the antidote often passes the window where it matters most. Advanced EMS systems internationally place the drug on units that respond to fires, with paramedics trained to administer it.

Houston Fire Department's deployment is a useful reference. They place Cyanokit on 10 EMS Supervisor vehicles and 21 District Chief vehicles, rather than every fire station. The reason: those units are dispatched to every working fire — better density than spreading it across every house. Their administration threshold is empirical: inhalation injury with altered mental status or abnormal vitals, no waiting for labs.

05 / Implementation

In November 2025, the New Taipei City Fire Department received three vials of Hydroxocobalamin. For a service area of 2,052 km² and a population of over four million, three vials could not cover every fire, so the team had to decide which responding units should carry them.

Adapting HFD's logic, the vials were placed where the drug is most likely to reach a fire scene with paramedics on board:

• Two TP+ advanced life support units — capable of advanced administration, fast activation, cross-district mobility
• One urban search and rescue team — routinely deployed to major fires, fully equipped

Placement considered both the units likely to attend a fire and the availability of trained personnel. Implementation included medical advisory committee review, an internal cyanide antidote protocol, Cyanokit Demokit hands-on training, and indication and dispatch protocol education.

06 / Outcome: field activation

In spring 2026, the protocol was activated for the first time. The dispatch center, for the first time in writing, issued the order:

The incident was an industrial fire. The drug was not administered, but the fact that it could be dispatched — those words appearing in writing — is a capability that did not exist for eleven years. Each activation, whether or not the drug is given, becomes real-world data for protocol review, medical advisory feedback, and training refinement.

The documented outcome is activation of the dispatch pathway. No drug was administered during this incident; it does not establish treatment effectiveness or a survival benefit.

07 / Lessons and next steps

Further work includes:

• Accumulating activation data to support expansion of placement
• Continued dialogue with the Ministry of Health and Welfare's toxicology unit on the value of prehospital placement
• Cross-jurisdictional sharing with EMS systems interested in implementation
• Continual update of training materials in response to AHA and international protocol revisions

Public documentation

• 2024-11 Visit to the United States: New Taipei City Government public overseas mission report C114AB007
• AHA 2025 Guidelines: Adult and Pediatric Special Circumstances of Resuscitation
• 2025-10 TEMS Newsletter publication: "Local Innovation: No Longer Powerless at the Fire Scene — Bringing Hydroxocobalamin to Prehospital Care"
• Other documentation (correspondence, deployment records, dispatch logs) is held internally and may be discussed on request.

Collaboration

I welcome discussion with EMS crews, medical directors and public health colleagues about introducing rarely used antidotes, preparing training materials and agreeing on responsibilities across services.

Read the personal story behind this work — eleven years from a loss to an open door →