282 Emergency Medicine
Benzodiazepines (eg, lorazepam) (b)are the first-line agents for an actively
seizing patient. Benzodiazepines are sedative hypnotics which increase
γ-aminobutyric acid (GABA) activity. Phenytoin (c)is a second-line anticonvul-
sant in a continuously seizing patient. It requires a loading dose and has to be
administered slowly because rapid administration may cause hypotension and
cardiac dysrhythmias. Rapid sequence intubation (RSI) (d)should not be per-
formed at this time. The patient’s pulse oximetry is 91% on room air and can
be improved by supplemental oxygen and a nasopharyngeal airway if neces-
sary. RSI should be done if the patient becomes apneic or his oxygen saturation
drops despite oxygen supplementation. (e)Once the acute seizure is con-
trolled, levels of the patient’s anticonvulsant medications should be checked
and supplemented if subtherapeutic.
251.The answer is d.(Hamilton et al, p 5.)The first question an emer-
gency physician asks for each patient is whether a life-threatening process
is causing the patient’s complaint. Emergency medicine is primarily a
complaint-oriented, rather than a disease-oriented specialty. Its emphasis
rests on anticipating and recognizing a life-threatening process rather than
seeking the diagnosis. The goal is to think about and plan to prevent the
life-threatening things from happening or progressing in the patient. The
patient in the vignette may have meningitis, a life-threatening condition, or
a viral syndrome with dehydration. The initial approach is stabilization
and treatment or prevention of a life-threatening process.This patient
requires fluid resuscitation for her BP, altered mental status, and delayed
capillary refill. Antibiotics should be started immediately and an LP per-
formed once increased ICP is evaluated by funduscopic examination or CT
scan. She should be placed in isolation. Her disposition is directed by her
response to initial resuscitation and results of the LP.
(a)It is important to collect blood cultures; however, initial stabiliza-
tion and treatment is priority. (b)The patient’s parents should be contacted
if the patient cannot do it herself, but treatment should proceed in the
meantime.(c)Gathering more information is invaluable; however, this
should be done after initial stabilization and treatment. (e)Observation in
a patient with a life-threatening condition is not recommended.
252.The answer is e.(Tintinalli, p 1288.)This patient presents with an
anion gap metabolic acidosis, glucosuria, and ketonuria, which is consistent
withdiabetic ketoacidosis (DKA).DKA is an acute, life-threatening disorder
occurring in patients with insulin insufficiency. It results in hyperglycemia,