ER
harry206 - 05-04-09 12:47

A 29-year-old Caucasian man is brought to the emergency department after he was found lying on the street, unconscious, and bleeding from his right leg. He was involved in a fight, and was stabbed twice in the right thigh. On arrival, his clothes are partially covered with snow. He is extremely pale, and his extremities are cold. His temperature is 35C (95F), blood pressure is 90/60 mm Hg, pulse is 120/min and respirations are 12/min. Examination shows decreased bilateral pulses, superficial breathing effort, clear lungs on auscultation, and decreased heart sounds. There is slow bleeding through one of the two penetrating wounds in his right thigh. The patient is stuporous, but does not have any focal neurological abnormality. He is emergently intubated and infused with warm fluids. His body is covered with warm blankets. The patient’s laboratory tests reveal:

CBC


Hb
6.3 g/dL

Ht
19%

MCV
92fl

Platelet count
150,000/cmm

Leukocyte count
4,500/cmm

Segmented neutrophils
65%

Lymphocytes
29%

Monocytes
6%



Serum chemistry


Serum Na
134 mEq/L

Serum K
3.8 mEq/L

Chloride
100 mEq/L

Bicarbonate
14 mEq/L

BUN
15 mg/dL

Serum Creatinine
0.7 mg/dL

Calcium
9.8 mg/dL

Blood Glucose
52 mg/dL



Because of the acute anemia, the patient receives a transfusion of packed red blood cells. He also receives parenteral glucose and thiamine, and his mental status slightly improves. He suddenly develops muscle spasms of the face and upper extremities, diaphoresis, and bilateral hand contracture. Fundoscopy reveals papilledema. He soon develops involuntary, repetitive, generalized tonic-clonic seizures. He is given intravenous lorazepam, which temporarily controls the abnormal movements. He then has another seizure episode. Which of the following is the most appropriate immediate step in the management of this patient?