Fatal Sodium Nitrite Poisoning: Key Considerations for Prehospital Providers

Matthew R. NethReceived July 3, 2020 from Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA (MRN, JSL, BZH, MRD); Tualatin Valley Fire & Rescue, Tigard, Oregon, USA (MRN, MRD); Oregon-Alaska Poison Center, Portland, Oregon, USA (JSL, BZH); Providence St. Vincent Medical Center, Portland, Oregon, USA (MDS); Washington County Emergency Medical Services, Hillsboro, Oregon, USA (RS). Revision received October 8, 2020; accepted for publication October 12, 2020.Correspondence[email protected]

https://orcid.org/0000-0002-3882-9637

, MD

Jennifer S. LoveReceived July 3, 2020 from Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA (MRN, JSL, BZH, MRD); Tualatin Valley Fire & Rescue, Tigard, Oregon, USA (MRN, MRD); Oregon-Alaska Poison Center, Portland, Oregon, USA (JSL, BZH); Providence St. Vincent Medical Center, Portland, Oregon, USA (MDS); Washington County Emergency Medical Services, Hillsboro, Oregon, USA (RS). Revision received October 8, 2020; accepted for publication October 12, 2020.

, MD,

B. Zane HorowitzReceived July 3, 2020 from Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA (MRN, JSL, BZH, MRD); Tualatin Valley Fire & Rescue, Tigard, Oregon, USA (MRN, MRD); Oregon-Alaska Poison Center, Portland, Oregon, USA (JSL, BZH); Providence St. Vincent Medical Center, Portland, Oregon, USA (MDS); Washington County Emergency Medical Services, Hillsboro, Oregon, USA (RS). Revision received October 8, 2020; accepted for publication October 12, 2020.

, MD,

Michael D. ShertzReceived July 3, 2020 from Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA (MRN, JSL, BZH, MRD); Tualatin Valley Fire & Rescue, Tigard, Oregon, USA (MRN, MRD); Oregon-Alaska Poison Center, Portland, Oregon, USA (JSL, BZH); Providence St. Vincent Medical Center, Portland, Oregon, USA (MDS); Washington County Emergency Medical Services, Hillsboro, Oregon, USA (RS). Revision received October 8, 2020; accepted for publication October 12, 2020.

, MD,

Ritu SahniReceived July 3, 2020 from Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA (MRN, JSL, BZH, MRD); Tualatin Valley Fire & Rescue, Tigard, Oregon, USA (MRN, MRD); Oregon-Alaska Poison Center, Portland, Oregon, USA (JSL, BZH); Providence St. Vincent Medical Center, Portland, Oregon, USA (MDS); Washington County Emergency Medical Services, Hillsboro, Oregon, USA (RS). Revision received October 8, 2020; accepted for publication October 12, 2020.

, MD, MPH &

Mohamud R. DayaReceived July 3, 2020 from Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA (MRN, JSL, BZH, MRD); Tualatin Valley Fire & Rescue, Tigard, Oregon, USA (MRN, MRD); Oregon-Alaska Poison Center, Portland, Oregon, USA (JSL, BZH); Providence St. Vincent Medical Center, Portland, Oregon, USA (MDS); Washington County Emergency Medical Services, Hillsboro, Oregon, USA (RS). Revision received October 8, 2020; accepted for publication October 12, 2020.

https://orcid.org/0000-0002-6910-8293

, MD, MS

Abstract

Sodium nitrite is a powerful oxidizing agent that causes hypotension and limits oxygen transport and delivery in the body through the formation of methemoglobin. Clinical manifestations can include cyanosis, hypoxia, altered consciousness, dysrhythmias, and death. The majority of reports on sodium nitrite poisonings have been the result of unintentional exposures. We report a case of an intentional fatal overdose of sodium nitrite. A 17-year-old female reportedly drank approximately one tablespoon of sodium nitrite in a self-harm attempt. The patient was hypotensive and cyanotic upon EMS arrival. The patient decompensated rapidly into a bradycardic arrest during transport despite intubation, push-dose epinephrine, and intravenous fluid resuscitation. In the Emergency Department (ED), she received methylene blue and packed red cells but could not be resuscitated despite a prolonged effort. EMS professionals should consider sodium nitrite toxicity in patients with a suspected overdose who present with a cyanotic appearance, pulse oximetry that remains around 85% despite oxygen, and dark brown blood seen on venipuncture. Early prehospital contact with the Poison Control Center and ED prenotification in poisoned patients is encouraged.

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