Understanding Altered Mental Status and Seizure Disorders

Key Clinical Signs:

• Onset: Slow.
• Skin: Warm, red, and dry.
• Breath: A distinct acetone (fruity) odor.
• Other: Intense thirst, increased urination, nausea, and deep breathing.

Clinical Management Tip: In the field, it can be difficult to distinguish between these two states. Because oral glucose is safe for hyperglycemic patients but life-saving for hypoglycemic ones, it is recommended to administer oral glucose to any diabetic patient with altered mental status, provided they are awake enough to swallow and can protect their airway.

Seizure Disorders

A seizure is a sudden change in sensation, behavior, or movement caused by irregular electrical activity in the brain. While many people associate seizures with violent shaking, they can manifest in much subtler ways.

Understanding Auras and Epilepsy

Some patients experience an aura before a seizure occurs. An aura is a sensory warning—such as a specific smell, sound, or general feeling—that signals an impending seizure.

Epilepsy is an umbrella term used to describe a condition where a person experiences multiple seizures of unknown cause.

Types of Seizures

Seizures are categorized based on how much of the brain is involved:

1. Partial Seizures

Partial seizures affect only one part of the brain.

• Simple Partial: These involve tingling, stiffening, or jerking of one part of the body, but the patient remains fully alert and conscious.
• Complex Partial: These involve abnormal behaviors such as lip-smacking, fidgeting, a "glassy stare," or aimless motion. While the patient remains conscious, they typically have no memory of the event.

2. Generalized Seizures

Generalized seizures affect the entire brain and always involve a loss of consciousness.

• Absence (Petit Mal): These are brief (about 10 seconds) lapses in awareness or concentration. They do not involve motor activity (shaking) and can occur many times a day.
• Tonic-Clonic: This is the most common generalized seizure seen by emergency responders. It involves major motor activity and follows three distinct phases:
  1. Tonic Phase: The body becomes rigid for up to 30 seconds; breathing may stop, and bowel/bladder control may be lost.
  2. Clonic Phase: The body undergoes violent jerking for 1 to 2 minutes; the patient may foam at the mouth or become cyanotic (blue).
  3. Postictal Phase: The seizure ends and consciousness is regained, but the patient is often drowsy, confused, or even violent.

Status Epilepticus

Status epilepticus is a critical medical emergency. It is defined as either a single seizure lasting longer than 10 minutes or two or more consecutive convulsive seizures without the patient regaining consciousness in between. This requires immediate transport and often Advanced Life Support (ALS) intervention.

Clinical Considerations and Patient Care

Causes of Seizures

Seizures can be triggered by various factors:

• Adults: Most commonly caused by failure to take prescribed anti-seizure medication.
• Infants/Children: Most commonly caused by high fever.
• Other: Hypoxia, stroke, trauma, toxins, hypoglycemia, brain tumors, and infections.

Emergency Care Guidelines

When managing a patient experiencing a seizure, your primary goal is to prevent injury and maintain the airway.

During the Seizure:

• Place the patient on the floor or ground.
• Loosen restrictive clothing.
• Clear the area of hard or sharp objects.
• DO NOT attempt to restrain the patient.
• DO NOT place anything in the patient's mouth.

After the Seizure:

• Protect the airway.
• If the patient is cyanotic, provide artificial ventilations with oxygen.
• Treat any injuries sustained during the convulsions.

Exam Tip: When describing a seizure to hospital staff, always try to gather "the story" from bystanders. Ask: Was there an aura? How long did it last? Was there a loss of bladder/bowel control? What did the patient do immediately after?