What is the most appropriate next step in managing a 24-year-old man with altered mental status, euphoria, and mild paranoia, presenting with hypotension, tachycardia, and injected sclerae?

Management of Altered Mental Status in a Young Adult with Euphoria and Paranoia

The most appropriate next step in management is observation in the emergency department (option A), as this patient's presentation is most consistent with cannabis intoxication that will likely resolve with time and supportive care.

Clinical Assessment and Reasoning

The patient presents with several key features that guide management:

• 24-year-old man found stumbling in yard
• Stable vital signs (BP 100/70 mmHg, pulse 90/min, respirations 16/min)
• Pupils equal and reactive to light with injected sclerae
• Inappropriate laughter and religious statements
• Food/drink seeking behavior
• Broad affect with mild paranoia but no other thought disorder

These symptoms strongly suggest substance intoxication rather than a life-threatening emergency. The constellation of symptoms—particularly the injected sclerae, inappropriate laughter, mild paranoia, and food-seeking behavior—is classic for cannabis intoxication 1.

Management Algorithm

1. Initial Stabilization

   • Confirm stable vital signs (already done)
   • Ensure airway is protected
   • Maintain patient safety

2. Rule Out Immediate Life Threats

   • Hypoglycemia: Not likely given the patient's mental status and food-seeking behavior
   • Opioid overdose: Not consistent with presentation (pupils are reactive, no respiratory depression)
   • Status epilepticus: No evidence of seizure activity
   • Severe trauma: No mention of trauma findings

3. Observation and Supportive Care

   • Monitor vital signs
   • Provide calm, quiet environment
   • Reassess mental status periodically

Why Other Options Are Less Appropriate

• Naloxone (Option B): Not indicated as there are no signs of opioid toxicity (no respiratory depression, pupils are reactive) 1.

• IV 50% Dextrose (Option C): Not indicated as the patient shows no signs of hypoglycemia. His food-seeking behavior suggests intact awareness of hunger, and his mental status is not consistent with hypoglycemia 1.

• IV Lorazepam (Option D): While benzodiazepines can be useful for agitated patients, this patient is not severely agitated or violent. Lorazepam could potentially worsen his altered mental status 1.

• Oral Chlorpromazine (Option E): Antipsychotics are not first-line for substance-induced altered mental status and could potentially worsen the patient's condition 1.

Important Considerations

• The patient's presentation is most consistent with cannabis intoxication, which typically resolves with time and supportive care.
• While observing the patient, continue to reassess for any changes in vital signs or mental status that might indicate a more serious condition.
• Avoid unnecessary medications that could complicate the clinical picture or worsen the patient's condition.

Potential Pitfalls

• Failing to consider other causes of altered mental status if the patient doesn't improve with observation
• Administering medications that could mask symptoms of underlying conditions
• Discharging the patient before mental status has normalized

In summary, for a young adult with this presentation of altered mental status, euphoria, mild paranoia, and stable vital signs, observation in the emergency department is the most appropriate next step to allow for monitoring while the likely substance-induced symptoms resolve naturally.