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EM@3AM: Cyanide Toxicity

A 13-year-old male is brought in by EMS for altered mental status after being found in a house fire. The fire department found burned couches in the house with melted plastic covering. His vital signs include BP 78/40, HR 155, T 99.9 Oral, RR 40, SpO2 92% on 15L NRB. He is somnolent but withdraws to pain. He has soot in his nares with carbonaceous sputum, and auscultation reveals rhonchorous and wheezing breath sounds bilaterally. Point of care VBG demonstrates a lactate of 16. What’s the next step in your evaluation and treatment?