7¬“µâ“πæ‘… Ò

‚´‡¥’¬¡‰π‰µ√å∑(Sodium nitrite)

√Õß»“ µ√“®“√¬å𓬷æ∑¬å«‘π—¬ «π“πÿ°Ÿ≈

¿“§«‘™“Õ“¬ÿ√»“ µ√å

§≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈

¬“µâ“πæ‘… ”À√—∫¿“«–æ‘…‡©’¬∫æ≈—π®“°‰´¬“‰π¥å (cyanide poisoning) ‰¥â·°à ‚´‡¥’¬¡‰π‰µ√å∑ (sodium

nitrite) ‰Œ¥√Õ°‚´‚§∫“≈“¡’π (hydroxocobalamin) ·≈–‚§∫Õ≈Õ’¥‘‡∑µ (cobalt edentate) π—Èπ ‚´‡¥’¬¡‰π‰µ√å∑

∂◊Õ‰¥â«à“‡ªìπ¬“∑’Ë¡’°“√„™â¡“π“π∑’Ë ÿ¥ ª√– ∫°“√≥å¢Õß°“√„™â¬“™π‘¥π’È¡’¡“°°«à“¬“µ—«Õ◊ËπÊ ∂÷ß·¡â«à“®–‡ªìπ

¬“Õ—πµ√“¬∑’ËÕ“®®–°àÕ„À⇰‘¥º≈Õ—π‰¡àæ÷ߪ√– ß§å‰¥â ·µàÀ“°„™âÕ¬à“ß∂Ÿ°µâÕß·≈–‡À¡“– ¡·≈â«‚´‡¥’¬¡‰π‰µ√å∑

®—¥«à“‡ªìπ¬“∑’Ë¡’ª√– ‘∑∏‘¿“楒„π°“√√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å ‚¥¬‡©æ“–„™â√à«¡°—∫‚´‡¥’¬¡

‰∏‚Õ´—≈‡øµ

‚´‡¥’¬¡‰π‰µ√å∑ ‡ªìπ “√Õπ‘π∑√’¬å¡’ Ÿµ√‡§¡’ Na2NO

2  “√≈–≈“¬ “√‰π‰µ√å∑„™â‡ªìππÈ”¬“ ”À√—∫·™à‡§√◊ËÕß

¡◊Õ·æ∑¬å‡æ◊ËÕªÑÕß°—π π‘¡ ®÷߇ªìπ¬“∑’Ë “¡“√∂‡µ√’¬¡‡Õ߉¥âßà“¬ ·≈–¡’√“§“∑’ˉ¡à·æ߇¡◊ËÕ‡∑’¬∫°—∫‰Œ¥√Õ°‰´‚§-

∫“≈“¡’π

‡¿ —™«‘∑¬“·≈–‡¿ —™®≈π»“ µ√å

¢∫«π°“√À“¬„®‚¥¬„™âÕÕ° ‘́‡®π (aerobic respiration) ¢Õ߇´≈≈凰‘¥¢÷Èπ„π‰¡‚µ§Õπ‡¥√’¬ (mitochondria)

¢∫«π°“√À“¬„®‚¥¬„™âÕÕ°´‘‡®ππ’ÈÕ“»—¬°“√‡§≈◊ËÕπ¬â“¬Õ‘‡≈Á°µ√Õπ (electron transportation) √–À«à“߉´‚µ‚§√¡

ÕÕ°´‘‡¥  (cytochrome oxidase) ∑”„À≥âæ≈—ßß“π∑’Ë®—¥‡°Á∫„π√Ÿªæ—π∏–øÕ ‡øµ∑’ˇ√’¬°«à“ ç‡Õ∑’æ’ (ATP, adenosine

triphosphate) ‚§√ß √â“ߢÕ߉´‚µ‚§√¡ÕÕ°´‘‡¥ π—Èπ¡’Õ–µÕ¡‡À≈Á°∑’Ë¡’ª√–®ÿ‡ªìπ∫«° “¡ (Fe3+) ´÷Ë߇√’¬°«à“

ç‡øÕ√å√‘° (ferric)é Õ¬Ÿà

‰´¬“‰π¥å´÷Ëß¡’ Ÿµ√‡§¡’§◊Õ CN ‡ªìπ‚¡‡≈°ÿ≈¢π“¥‡≈Á° ‡¡◊ËÕ “√‰´¬“‰π¥å‡¢â“ Ÿà√à“ß°“¬ ®÷ß “¡“√∂‡¢â“‰ª

„πÕÕ√å°“‡π≈¢Õ߇´≈≈åµà“ßÊ ¢Õß√à“ß°“¬‰¥â¥’ ‚¥¬ “¡“√∂‡¢â“‰ª∂÷ß„π‰¡‚µ§Õπ‡¥√’¬ ·≈–‡π◊ËÕß®“°‰´¬“‰π¥å

 “¡“√∂®—∫°—∫‡À≈Á°„π√Ÿª¢Õ߇øÕ√å√‘°‰¥â¥’ ‡¡◊ËÕ‡¢â“‰ª„π‰¡‚µ§Õπ‡¥√’¬ ‰´¬“‰π¥å¡—°®—∫°—∫‰´‚µ‚§√¡ÕÕ°´‘‡¥ 

¡’º≈„À⢗¥¢«“ߢ∫«π°“√‡§≈◊ËÕπ¬â“¬Õ‘‡≈Á°µ√Õπ ´÷ËßÀ¡“¬∂÷ߢ∫«π°“√À“¬„®‚¥¬„™âÕÕ°´‘‡®π≈¥≈ß ‡π◊ÈÕ‡¬◊ËÕ„π

√à“ß°“¬®÷߉¡à “¡“√∂„™âÕÕ° ‘́‡®π‰¥âµ“¡ª°µ‘ ‡°‘¥‡ªìπ¿“«–∑’ˇ√’¬°«à“ ç°“√¢“¥ÕÕ° ‘́‡®π„π√–¥—∫‡´≈≈å (histotoxic

hypoxia)é

 “√‚´‡¥’¬¡‰π‰µ√å∑¡’§ÿ≥ ¡∫—µ‘‡ªìπ “√ÕÕ°´‘‰¥´å (oxidizing agent) ‡¡◊ËÕ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”®–

oxidize ‡À≈Á°„πŒ’‚¡‚°≈∫‘π´÷Ëß¡’ª√–®ÿ∫«° Õß (Fe2+) ∑’ˇ√’¬°«à“‡øÕ√å√—  (ferrus) „À⇪ìπ‡øÕ√å√‘°∑’Ë¡’ª√–®ÿ∫«° “¡

(Fe3+) ¡’º≈„À⌒‚¡‚°≈∫‘π„π‡¡Á¥‡≈◊Õ¥·¥ß‡ª≈’ˬπ‡ªìπ‡¡∏Œ’‚¡‚°≈∫‘π (methemoglobin) ´÷Ëß “¡“√∂®—∫°—∫ “√

‰´¬“‰π¥å‰¥â¥’ °≈“¬‡ªìπ‰´¬“‚π‡¡∏Œ’‚¡‚°≈∫‘π (cyanomethemoglobin) ¡’º≈„À≴‚µ‚§√¡ÕÕ° ‘́‡¥ „π‰¡‚µ§Õπ‡¥√’¬

8 ¬“µâ“πæ‘… Ò

‡ªìπÕ‘ √–·≈–‡´≈≈å¡’°“√À“¬„®‚¥¬„™âÕÕ°´‘‡®πµ“¡‡¥‘¡µ“¡√Ÿª∑’Ë 1

√Ÿª∑’Ë 1 · ¥ß°≈‰°°“√‡°‘¥æ‘…¢Õ߉´¬“‰π¥å·≈–°≈‰°°“√·°âæ‘…¢Õß‚´‡¥’¬¡‰π‰µ√å∑

πÕ°®“°°≈‰°¢â“ßµâπ·≈â« ‚´‡¥’¬¡‰π‰µ√å∑¡’°≈‰°°“√ÕÕ°ƒ∑∏‘ÏÕ◊Ëπ‚¥¬ºà“π∑“߉πµ√‘°ÕÕ°‰´§å (nitric

oxide) ‡π◊ËÕß®“°‰π‰µ√å∑‡ªìπ “√µ—Èßµâπ (precursor) ¢Õ߉πµ√‘°ÕÕ°‰´§å ́ ÷Ëß¡’º≈„ÀâÀ≈Õ¥‡≈◊Õ¥·¥ß¢¬“¬µ—« ∑”„Àâ

¡’‡≈◊Õ¥·≈–ÕÕ°´‘‡®π Ÿà‡´≈≈å‡æ‘Ë¡¢÷Èπ

¢âÕ∫àß„™â

1. „™â√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å ‚¥¬„™â√à«¡°—∫‚´‡¥’¬¡‰∏‚Õ´—≈‡øµ (sodium thiosulfate)

¬°‡«âπ °√≥’¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å∑’ˇ°‘¥®“°°“√ Ÿ¥¥¡§«—πæ‘…®“°°“√‡º“‰À¡â (smoke inhalation)

2. Õ“®®–„™â‡æ◊ËÕ√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉Œ‚¥√‡®π´—≈‰øµå ¿“¬„π 30 π“∑’·√°¢Õß°“√‡°‘¥æ‘…

¢âÕÀâ“¡„™â

1. ºŸâªÉ«¬¡’√–¥—∫‡¡∏Œ’‚¡‚°≈∫‘π Ÿß (¡“°°«à“√âÕ¬≈– 40) √à«¡¥â«¬µ—Èß·µà°àÕπ°“√√—°…“¥â«¬‚´‡¥’¬¡

‰π‰µ√å∑

2. ¿“«–µàÕ‰ªπ’È ‰¡à∂◊Õ«à“‡ªìπ¢âÕÀâ“¡ ¡∫Ÿ√≥å·µàµâÕß√–¡—¥√–«—߇ªìπ摇»…

2.1 ºŸâªÉ«¬¡’¿“«–§«“¡¥—π‚≈À‘µµË” À√◊Õ™ÁÕ§ ‡π◊ËÕß®“°‚´‡¥’¬¡‰π‰µ√å∑Õ“®®–∑”„À⧫“¡¥—π

‚≈À‘µµË”¡“°¢÷Èπ

2.2 ¡’¿“«–§“√å∫Õπ¡ÕπÕÕ°‰´§å‡ªìπæ‘…√à«¡¥â«¬ ‡π◊ËÕß®“°°“√„Àâ‚´‡¥’¬¡‰π‰µ√å∑°àÕ„À⇰‘¥

¿“«–‡¡∏Œ’‚¡‚°≈∫‘ππ’‡¡’¬ (methemoglobinemia) ´÷Ëß∑”„Àâ°“√¢π àßÕÕ°´‘‡®π‰ª¬—߇π◊ÈÕ‡¬◊ËÕµà“ßÊ ≈¥≈ß

9¬“µâ“πæ‘… Ò

¿“«–Õ—π‰¡àæ÷ߪ√– ß§å®“°¬“

1. À“°‚´‡¥’¬¡‰π‰µ√å∑∑’Ë„ÀⷰຟâªÉ«¬‡Àπ’ˬ«π”„À⌒‚¡‚°≈∫‘π‡ª≈’ˬπ‡ªìπ‡¡∏Œ’‚¡‚°≈∫‘π¡“°‡°‘π‰ª

®–∑”„À⇰‘¥Õ—πµ√“¬·°àºŸâªÉ«¬‰¥â ¢π“¥¬“∑’Ë·π–π”¡—°®–‡Àπ’ˬ«π”∑”„À⇰‘¥‡¡∏Œ’‚¡‚°≈∫‘π√âÕ¬≈– 8-15 ‡∑à“π—Èπ

√–¥—∫‡¡∏Œ’‚¡‚°≈∫‘π∑’Ë Ÿß√à«¡°—∫‰´¬“‰π¥å‡ÕßÕ“®∑”„À⺟âªÉ«¬¡’¿“«–æ√àÕßÕÕ° ‘́‡®π√ÿπ·√ß®πÕ“®∑”„À⇠’¬™’«‘µ‰¥â

2. °“√∫√‘À“√¬“‚´‡¥’¬¡‰π‰µ√å∑“ßÀ≈Õ¥‡≈◊Õ¥¥”‡√Á«‡°‘π‰ª Õ“®∑”„À⧫“¡¥—π‚≈À‘µµ°‰¥â

3. Õ“°“√ª«¥»’√…– §≈◊Ëπ‰ â À—«„®‡µâπ‡√Á«·≈–‡Àß◊ËÕÕÕ°¡“° æ∫‰¥âπâÕ¬„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“ ∫“ߧ√—Èß

√à«¡°—∫¿“«–§«“¡¥—π‚≈À‘µµË”≈ß

ªØ‘°‘√‘¬“µàÕ¬“Õ◊Ëπ

1. À“°¡’√–¥—∫·Õ≈°ÕŒÕ≈å„π‡≈◊Õ¥ À√◊Õ„™â¬“¢¬“¬À≈Õ¥‡≈◊Õ¥™π‘¥Õ◊Ëπ√à«¡¥â«¬ ®–∑”„À⧫“¡¥—π

‚≈À‘µµË”≈ß¡“°

2. °“√∫√‘À“√¬“‡¡∏‘≈’π∫≈Ÿ (methylene blue) ‡¡◊ËÕ‡°‘¥¿“«–‡¡∏Œ’‚¡‚°≈∫‘ππ’‡¡’¬ ®“°¬“‚´‡¥’¬¡‰π‰µ√å∑

®–∑”„À⇰‘¥¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å°≈—∫¡“„À¡à ®÷߉¡à§«√∫√‘À“√¬“‡¡∏‘≈’π∫≈Ÿ√à«¡°—∫¬“‚´‡¥’¬¡‰π‰µ√å∑

¢π“¥·≈–«‘∏’ „™â

°“√√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å¥â«¬¬“‚´‡¥’¬¡‰π‰µ√∑å „™â√à«¡°—∫¬“‚´‡¥’¬¡‰∑‚Õ´—≈‡øµ

‚¥¬©’¥‚´‡¥’¬¡‰∑‚Õ´—≈‡øµ µ“¡À≈—߬“‚´‡¥’¬¡‰π‰µ√∑剥â∑—π∑’

1. ºŸâ„À≠à

¢π“¥ 300 ¡‘≈≈‘°√—¡ (10 ¡‘≈≈‘≈‘µ√¢Õß “√≈–≈“¬ 3% ‚´‡¥’¬¡‰π‰µ√å∑) ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

„π‡«≈“¡“°°«à“ 3-5 π“∑’

2. „π‡¥Á°

¢π“¥ 10 ¡‘≈≈‘°√—¡/°‘‚≈°√—¡ À√◊Õ 0.33 ¡‘≈≈‘≈‘µ√/°‘‚≈°√—¡¢Õß “√≈–≈“¬ 3% ‚´‡¥’¬¡‰π‰µ√å∑

·µà‰¡à§«√¡“°°«à“ 10 ¡‘≈≈‘≈‘µ√ (300 ¡‘≈≈‘°√—¡) ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

πÕ°®“°π—Èπ§«√µ√«®√–¥—∫Œ’‚¡‚°≈∫‘π·≈–ª√—∫¢π“¥¬“µ“¡Œ’‚¡‚°≈∫‘𠵓¡µ“√“ߢâ“ß≈à“ßπ’È

Œ’‚¡‚°≈∫‘π

°√—¡/‡¥´‘≈‘µ√

7

8

9

10

11

12

13

¢π“¥¬“ 3% ‚´‡¥’¬¡‰π‰µ√å∑

¡‘≈≈‘°√—¡/°‘‚≈°√—¡

5.8

6.6

7.5

8.3

9.1

10.0

10.8

¢π“¥¬“ 3% ‚´‡¥’¬¡‰π‰µ√å∑

¡‘≈≈‘≈‘µ√/°‘‚≈°√—¡

0.19

0.22

0.25

0.27

0.30

0.33

0.36

10 ¬“µâ“πæ‘… Ò

‡¡◊ËÕ„À⬓‚´‡¥’¬¡‰π‰µ√å∑·≈⫧«√µ“¡¥â«¬¬“‚´‡¥’¬¡‰∏‚Õ —́≈‡øµ‡ ¡Õ ¬“¡—°®–ÕÕ°ƒ∑∏‘χµÁ¡∑’Ë¿“¬„π

30 π“∑’ À≈—ß®“° 30 π“∑’‰ª·≈â« À“°¬—߉¡à‡ÀÁπ°“√µÕ∫ πÕßÕ“®æ‘®“√≥“„Àâ´È”Õ’°§√÷ËßÀπ÷ËߢÕß¢π“¥‡√‘Ë¡µâπ

Õ’° 1§√—Èß

√Ÿª·∫∫¢Õ߬“

 “√≈–≈“¬ 3% ‚´‡¥’¬¡‰π‰µ√å∑À≈Õ¥≈– 10 ¡‘≈≈‘≈‘µ√ (30 ¡‘≈≈‘°√—¡/ ¡‘≈≈‘≈‘µ√) º≈‘µ‚¥¬ ∂“π‡ “«¿“

 ¿“°“™“¥‰∑¬

‡Õ° “√ª√–°Õ∫°“√‡√’¬∫‡√’¬ß

1. WHO: Antidotes and other substances used in poisonings. 2008. Chapter:4. WHO Model Formulary. Page

65-66. www.who.int/selection_medicines/list/WMF2008.pdf Date accessed:07/12/2009

2. US DHHS: Medical Management Guidelines for Hydrogen Cyanide. 2007. Medical Management Guidelines

page12,18. http://www.atsdr.cdc.gov/MHMI/mmg8.html Available from:14/12/2009

3. Holdstege CP, Isom GE, Kirk, MA. Cyanide and hydrogen sulfide. In: Flomenbaum NE, Goldfrank LR,

Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrankû toxicologic emergencies.8th ed. New York:

McGraw-Hill; 2006:p1712-24.

4. Curry SC. Cyanide: hydrogen cyanide, inorganic cyanide salts and nitriles. In Bent J, Wallace KL, Burkhart KK,

Phillips SD, Donovan JW, eds. Critical care toxicology: Diagnosis and management of the critically poisoned

patient. Philadelphia: Mosby Inc;2005:p987-98.

5. Howland MA. Sodium and Amy nitrite. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin

NA, Nelson LS, eds. Goldfrankû toxicologic emergencies.8th ed. New York: McGraw-Hill; 2006:p1725-27.

6. Andreson BD. Nitrites. in Bent J, Wallace KL, Burkhart KK, Phillips SD, Donovan JW, eds. Critical care

toxicology: Diagnosis and management of the critically poisoned patient. Philadelphia: Mosby Inc; 2005:

p1539-42.

7. Mullen WH. Nitrire, sodium and amyl. In Olson KR, ed. Poison & Drug overdose. 5th ed. New York:

McGraw-Hill;2007:p484-5.

8. Wananukul W, Kaojarern S. Acute Cyanide Poisoning: A case report with toxicokinetic study. J Med Assoc

Thai 1992;75:304-309.