SAEM Clinical Image Series: Found Down with Altered Mental Status

A forty-nine-year-old male with a history of polysubstance abuse, including methamphetamine and intravenous (IV) drug use, rectal cancer, and human immunodeficiency virus (HIV) was brought into the emergency department by emergency medical services (EMS) after he was found down at the bottom of a flight of stairs by his roommate. In the emergency room, he was found to have a Glasgow Coma Scale (GCS) score of 7 and was intubated for airway protection. Non-contrast head CT was performed. Per the roommate, the patient had been “not himself,” exhibiting strange behavior and weight loss. History and review of systems (ROS) were otherwise unobtainable due to the acuity of illness.




Fiona is a 6 year old female who presents to your emergency department after falling onto her left hand while racing on the playground. X-ray of the left upper extremity reveals a distal radius fracture with minimal displacement and angulation. You plan to place her arm in a splint and arrange for close orthopedic follow-up. The only problem: Fiona is in a lot of pain, especially with any manipulation of her arm, and Dad is worried that she will not be able to tolerate having a splint placed. You consider reaching for an intranasal medication to help Fiona feel more comfortable and to place the splint in a quick, efficient manner.