Question of the Week

For December 11, 2018

A 17-year-old boy is brought to the emergency department with altered mental status after being found on the front lawn of a neighbor’s house. He reports that he consumed substantial amounts of alcohol over the course of several hours at a friend’s house but did not use any other recreational drugs. He denies any suicidal ideation or suicide attempt. He has had no vomiting, diarrhea, or difficulty breathing.

His parents report that he has been "moodier" lately and that he has had behavioral difficulties at home and school during the past 6 months. His grades have also been declining. He has been spending time with a new group of friends and was in a physical altercation 2 weeks ago.

His temperature is 36.5°C, his blood pressure is 100/62 mm Hg, his respiratory rate is 10 breaths per minute, his heart rate is 54 beats per minute, and his oxygen saturation is 98% while he is breathing ambient air. His mucous membranes are moist, and he is not drooling.

He is agitated, confused, and oriented only to person, not place or time. His speech is slurred, and his breath smells of alcohol. His pupils are equal at 4 mm bilaterally and are reactive to light; there is no nystagmus. His conjunctivae are injected. His neck is supple. He is responsive to commands but with slowed motor movements and poor coordination. There are no signs of external head trauma or rash. When the patient falls asleep, his respiratory rate drops to 6 breaths per minute.

A fingerstick glucose level is measured at 72 mg/dL (reference range, 70–105).

In addition to protecting this patient's airway and establishing intravenous access, what is the most appropriate medication to administer next?

Lorazepam
Flumazenil
Naloxone
Fomepizole
Pralidoxime