249.A 79-year-old man presents to the ED by paramedics with the chief
complaint of agitation and confusion over the previous 12 hours. He has
a past medical history of schizophrenia and is not taking any of his
antipsychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR
is 18 breaths per minute, oxygen saturation is 97% on room air, and finger-
stick glucose is 135 mg/dL. Because of his agitation at triage, he was placed
in wrist restraints. At this time, he is calm but confused. Examination
reveals warm and clammy skin and 4-mm pupils that are equal and reactive.
His cardiac examination reveals tachycardia and no murmurs. His lungs are
clear to auscultation and his abdomen is soft and nontender. He is able to
move all of his extremities. Which of the following is the most appropriate
next step in management?
a. Administer haloperidol or lorazepam
b. Consult psychiatry
c. Order a CT scan of his head
d. Send a urine toxicologic screen
e. Obtain a rectal temperature
250.A 25-year-old man is brought to the ED by emergency medical ser-
vice (EMS) accompanied by his girlfriend who reports that the patient had
a seizure 30 minutes ago and is still confused. The girlfriend reports that
the patient is a known epileptic who has been doing well on his latest med-
ication regimen. The exact seizure medications are unknown. On arrival to
the ED, the patient develops continuous clonic movements of his upper
and lower extremities. The patient’s vital signs are BP of 162/85 mm Hg,
HR of 110 beats per minute, and pulse oximetry of 91% on room air. Cap-
illary glucose level is 95 mg/dL. Which of the following is the most appro-
priate next step in management?
a. Place the patient in a lateral decubitus position.
b. Administer lorazepam.
c. Administer phenytoin.
d. Perform rapid sequence intubation on the patient.
e. Look up the patient’s medical records and administer his current antiepileptic
regimen.
268 Emergency Medicine