You make it up to the unit. From the doorway, it's obvious that he's having right arm jerking movements again. However, he's alert and immediately looks at you, welcoming you to his room. His responds well to your questions. So, knowing that he has focal status with preserved awareness, you do try to treat with IV lorazepam 2mg (it's been going on for five minutes at this point). You also re-load with levetiracetam and increase the maintenance dose.
These maneuvers don't work, but he's still alert and oriented. You opt to load with IV lacosamide 400mg and start maintenance a 100mg bid. While this seems to help at first, an hour later, he starts to become somnolent. At this point, you commit to intubating and sedating him, as this change in his mental status means we need to prioritize this over choosing more ASMs in the interim. You also get a repeat non-contrast head CT, which is stable.
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