Altered Mental Status

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Altered Mental Status

• Seizure and Syncope

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Seizure

• Massive electrical discharge in a group of nerve
  cells in the brain
• Causes change in mental behavior
• Range from trancelike periods of inattention to
  unresponsiveness and jerky muscle spasms known as
  convulsions
• Common cause is epilepsy
• Chronic brain disorder characterized by recurrent
  seizures

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Types of Seizures

• Generalized Tonic-Clonic Seizure (Grand Mal)
• Simple Partial Seizure
• Complex Partial Seizure
• Absence (Petit Mal ) Seizure
• Febrile Seizure

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Generalized Tonic-Clonic Seizure

• Called Grand Mal Seizure
• Most common type of Epileptic Seizure
• Usually occurs in 4 stages
• Aura
• Tonic phase
• Clonic phase
• Postictal state

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Aura

• Warning that seizure is going to begin
• Involves sensory perception
• Sound, abnormal twitch, anxiety, dizziness smell
  or odor, odd taste, visual disturbances,
  unpleasant feeling in the stomach
• Tell patient to let you know if he is going to
  seize
• Can have seizure without the Aura

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Tonic Phase

• Patient becomes unresponsive and falls to the
  ground
• Typically follows Aura
• Muscles become contracted and tense
• Extreme muscle rigidity and arching back

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Clonic Phase

• Convulsions
• Muscle spasms alternating with relaxation
• Produce violent and jerky seizure activity
• Loss of bladder and bowel control
• May bite tongue, lips, or mouth
• Breathing may be shallow or absent
• Usually last 1 to 3 minutes

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Postictal State

• Recovery phase
• Complete unresponsiveness to confusion and
  disorientation
• Mental status improves over time
• Exhaustion and embarrassment
• May have a headache and hemiparesis
• Usually lasts 10 to 30 minutes

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Emergency Care

• Maintain airway - Insert NPA if patient is
  unresponsive
• Never force anything into the patients mouth
• Big Os With NR or begin positive pressure
  ventilation
• Position the patient
• Left lateral recumbent or supine and fully
  immobilized, but be ready for vomiting
• Suction as needed
• Assist breathing if seizure lasts longer than 5
  minutes
• Protect the patient from hurting themselves
• Transport

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Simple Partial Seizure

• Known as focal motor or Jacksonian motor seizure
• Jerky muscle activity in one area, arm, leg, or
  face
• Patient remains awake and aware of activity
• Can spread and become generalized tonic-clonic
  seizure
• Document where activity began and spread

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Emergency Care

• Recurring problem transport may not be necessary
• First time seizure transport for further
  evaluation
• Contact medical control or follow protocol

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Complex Partial Seizure

• Also known as psychomotor or temporal lobe
  seizure
• Usually starts with blank stare, followed by
  random activity such as lip smacking, chewing, or
  rolling the fingers
• Appears dazed, unaware of surroundings
• Mumbles or repeats certain word phrases
• Clumsy movements
• picks at or removes clothing
• Patient may struggle with you or show abrupt
  personality changes

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Emergency Care

• Speak calm and reassuringly to the patient
• Guide patient away from hazards
• Stay with patient until he is aware of
  surroundings
• Will most likely refuse transport
• Contact medical control or follow protocol

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Absence (Petit Mal) Seizure

• Most common in children
• Blank stare beginning and ending abruptly, only
  lasting a few seconds
• Rapid blinking, some chewing movements, lack of
  attention
• Unaware during seizure, awareness returns after
  seizure stops
• No emergency may be needed, but first time
  activity, medical evaluation should be recommended

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Febrile Seizure

• Common in children between 6 months to 6 years
• Caused by high fever
• Affects approximately 5
• Generalized seizure, short duration
• No emergency may be needed, but first time
  activity, medical evaluation should be
  recommended
• If seizure last longer than 15 minutes or recurs
  without recovery period, transport immediately
• Status epilepticus, true medical emergency

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Scene Size-Up

• Assess scene for clues
• Look for any head injury
• Most commonly in postictal state upon arrival
• Do not hold patient down, guide movements
• Move objects away from patient
• Never place anything in mouth
• Be prepared to use AED if no pulse is found

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Initial Assessment

• Assess A,B,Cs
• Status epilepticus - seizures that last longer
  than 10 minutes with no period of responsiveness
  between them (true emergency)

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Categories for Priority Transport

• Patient remains unresponsive after seizure
• Any inadequacy of A,B,Cs
• Second seizure occurs without a period of
  responsiveness
• Seizure last longer than 5 minutes
• Pregnant, history of diabetes, or trauma
• Seizure occurred in water
• Evidence of head trauma

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Focused History/Physical Exam

• Postictal or altered mental status rapid
  assessment
• Assess head, pupils, look for medical alert tags
• Assess for fractures
• SAMPLE History
• Ongoing assessment
• Prepare for other seizures

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Patients Medications

• Dilantin
• Phenobarbital
• Zarontin
• Tegretol
• Depakote
• Mysoline
• Clonopin
• Traxene
• Felbatol

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Emergency Care

• Maintain airway - Insert NPA if patient is
  unresponsive
• Never force anything into the patients mouth
• Big Os With NR or begin positive pressure
  ventilation
• Position the patient
• Left lateral recumbent or supine and fully
  immobilized, but be ready for vomiting
• Suction as needed
• Assist breathing if seizure lasts longer than 5
  minutes
• Protect the patient from hurting themselves
• Transport

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Syncope

• Fainting - lack of blood flow to the brain
• Can be confused with a seizure
• Difference
• Episode begins in a standing position
• Patient remembers feeling faint or lightheaded
• Patient becomes responsive almost immediately
  after becoming supine
• Skin is usually pale and moist

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Emergency Care

• Ensure airway
• Consider c-spine
• Elevate legs if no spinal injury suspected
• NR. mask with 15 lpm. O2
• Assess vital signs
• Transport
• Consult medical control or follow protocol
• If patient is not responding appropriately
  consider altered mental status and treat
  accordingly