We gratefully acknowledge the concerns put forward in the letter from Dr. Bebarta (Bebarta, Citation2012). Regarding the first concern, the antidote hydroxocobalamin interferes with the spectrophotometric method for cyanide that was used before 2002. Hydroxocobalamin was established as a cyanide antidote in 1996 in Sweden under the name “Cyanokit”. However, Cyanokit was only sold under license until it was registered as a prescription medicine in 2009. Unfortunately, we have no information on how many of the 225 victims (1992–2002) that were treated with hydroxocobalamin. However, only about 50 Cyanokit licences were granted annually in that period and it appears that the use was rare and confined to hospitals. Even today, prehospital use is fairly uncommon. The limited use of Cyanokit in the early years suggests that the use of an unspecific spectrophotometric method only has a marginal impact on the overall picture of pre-2002 cyanide levels.
The second concern of Dr. Bebarta is that patients that have received hydroxocobalamin will exhibit reduced or undetectable cyanide levels, resulting in an underestimate of the “true” cyanide exposure. Again, we do not have information on how many of the deceased that had been treated with hydroxocobalamin, or any cyanide antidote for that matter. The potential for underestimated cyanide exposure does not contradict our main conclusion (Stamyr et al., Citation2012) that hydrogen cyanide contributes more to the cause of death among fire victims than previously thought.
Declaration of interest
The authors report no conflicts of interest.
Supplementary Material
Download PDF (510.5 KB)References
- Bebarta VS. Hydrogen cyanide related deaths and detection in the blood. 2012. Inhal Toxicol 24:687.
- Stamyr K, Thelander G, Ernstgård L, Ahlner J, Johanson G. 2012. Swedish forensic data 1992-2009 suggest hydrogen cyanide as an important cause of death in fire victims. Inhal Toxicol 24:194–199.