I’m going to illicit responses from the readership on this one…
You are called to the scene for a 42 year old male having a seizure. On arrival you find a family member talking to the patient, who was placed in a left lateral recumbent position for recovery. You leave your partner and the assisting engine crew to go and grab a vial of midazolam and a mucosal atomizer. When you return, the patient is now up and fighting off 4 grown men. When he is finally wrestled to the ground and restrained, you move in and administer 5 mg of midazolam IN (intranasal). After what seems like an eternity, the patient finally stops fighting and is able to walk with assistance to the cot, and is quickly moved into the ambulance. The patient’s mental status slowly returns en route and you are able to finally obtain vital signs and a brief H&P:
HR: 122, sinus tachycardia without ectopy
RR: 22 regular, decreasing in rate with passing of the postictal phase
Blood sugar: 112 mg/dL
PMHx: asthma when he was younger, now takes no medications, allergic to Demerol only. No previous seizure history in either the patient or his biological family.
Pt is a healthy looking adult male, skin is hot, flushed, and diaphoretic which dissipated over time. No fever is noted. Pupils are dialated and sluggish, no JVD is noted. No pain on movement of the neck. RR is rapid but a regular depth for someone who just ran a literal marathon. The lung fields in all fields are clear, heart tones are normal. The abdomen is soft and non-tender to palpation, incontinence of urine is noted, + pulse, motor, and sensory. Pt is slightly sedated from midazolam use.
What’s your differential diagnosis and treatment scheme? Don’t be shy!