INSTRUCTOR GUIDE
Topic: Altered Mental Status: Assessing and Managing Seizure Patients
Time Required: 3 hours
Teaching/Learning Materials: Easel pad and markers or board and chalk
References: Brady Emergency Care, 10th ed. (pp. 430-433, 771-772), Maryland Protocols for
Emergency Services (pp. 37, 209, 210)
Motivation: The brain functions normally when there is an orderly, organized, coordinated discharge of
electrical impulses. These impulses enable the brain to communicate with the spinal cord and the
peripheral nerves, which control the muscles. Disruption of the electrical impulses causes seizures,
leaving the patient in an altered mental state for a period of time. The patient will be unable to control
body functions when seizing. EMTs must be familiar with causes and different types of seizures, which
have varying signs and symptoms. EMTs must also respond quickly with proper patient care.
Student Performance Objective: Given information, resources, and opportunity for discussion and
practice, at the completion of this session, EMTs will be able to list causes, types, and signs and
symptoms of seizures, describe patient care procedures and demonstrate patient assessment and
care. EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for
Emergency Medical Providers.
Enabling Objectives
1-1
List the causes of seizures.
1-2
List types of seizures and their signs and symptoms
1-3
Describe and demonstrate patient care procedures.
Overview:
 Causes of Seizures
 Types of Seizures and Their Signs and Symptoms
 Patient Care Procedures
I.
Causes of Seizures
A. Causes by age group
1. Age 6 months to 3 years (Seizures do not occur once any of the following
abnormalities/triggers are resolved; if it does recur without the trigger, the cause is likely
from a birth injury, a birth defect, or a hereditary metabolic abnormality, or a brain
disorder)
a. Common: high fever (febrile seizures)
b. Metabolic abnormalities
1) High or low sugar or sodium levels
2) Low calcium or magnesium levels
3) Vitamin B6 deficiency
2. Age 2 to 14 years: Often, the cause is unknown but may be the result of measles,
mumps, and other childhood diseases
3. After age 25: For about half the people in this age group, the cause is unknown
a. Head injury (trauma)
b. Stroke
c. Tumor
d. Alcohol withdrawal
1) Seizure and altered mental state are two signs of delirium tremens, an indication
of alcohol withdrawal
2) May result in death
a) 35% if untreated
b) <5% if recognized and treated early
B. Other causes for any age group
1. Idiopathic: Occurring spontaneously with no identifiable cause (common in children)
2. Conditions that irritate the brain
a. Injury
b. Certain prescription or recreational drugs and drug withdrawal
c. Sleep deprivation
d. High fever
1) Heat stroke
2) Infection
3. Conditions that deprive the brain of oxygen or fuel (provoked seizure, usually nonepileptic; however, these conditions can cause seizure in epileptic patients, so history is
important)
a. Low level of oxygen
1) Abnormal heart rhythm
2) Carbon monoxide poisoning
3) Near drowning
4) Stroke
b. Metabolic disorders
1) High or low level of sugar or sodium
2) Low level of calcium or magnesium
3) Kidney or liver failure
4. Structural damage to the brain
a. Noncancerous or cancerous tumor
b. Trauma to the head and intracranial bleeding
c. Stroke
5. Exposure to toxins, such as lead and strychnine
6. Fluid accumulation in the brain from eclampsia (with signs and symptoms of seizure,
altered mental status; headache; visual disturbances; abdominal pain)
7. Rare causes or triggers (reflex epilepsy)
a. Repetitive sounds
b. Flashing lights
c. Video games
d. Touching certain body parts
II.
Types of Seizures (two categories—partial and generalized)
A. Partial: Begin in a focal (limited or focused) part of the brain (again, two categories, simple
and complex)
1. Simple partial seizure
a. Also called motor, sensory, or Jacksonian (named for the English neurologist, John
Hughlings Jackson, who studied speech defects in brain disorders) seizures
b. Patient may experience a tingling (starting with the fingers and moving proximally—
this “epileptic march” was identified by Jackson), twitching of muscles or extremities,
turn his or her head, have visual changes, or dizziness
c. Patient may experience an aura (sensation of smelling odors, seeing lights or
colors, or feeling butterflies the stomach
d. First aid
1) Do not restrain
2) Remove items to avoid patient injury and guide away from danger
2. Complex partial seizure
a. Also called psychomotor or temporal lobe seizures
b. Often preceded by an aura
c. Signs and symptoms
1) Patient may act confused and may have no memory of the episode afterward
2) Patient may display some abnormal behavior, which may or may not be noticed
by others
3) Staring, a sense of déjà vu, visual hallucinations
4) Aimless moving around, fidgeting, or repetitive motion
5) Smacking or chewing the lips
6) Smelling unpleasant odors
7) Possibly struggling if restrained
8) Patient may have an altered mental state (loss of consciousness
d. First aid
1) Do not restrain
2) Remove items to avoid patient injury and guide away from danger
B. Generalized seizures: Involve larger areas of the brain, affecting both sides at the same time
(compare to partial seizures, affecting one focused part of the brain) and include four types
1. Tonic (referring to muscle tone or rigidity)-clonic (referring to spasm); Grand mal seizure
a. The patient may or may not experience an aura
b. The patient will often cry out before falling to the floor
c. The patient will become unconscious (altered mental state)
d. The patient will have major motor activity, thrashing wildly, of the entire body
e. The seizure will last from 1 to 5 and possibly up to 20 minutes
f. The seizure has three distinct phases
1) Tonic (think muscle tone and hard, rigid muscles)
a) The body becomes rigid for about 30 seconds
b) The patient may stop breathing during this time, but will resume
c) The patient will rarely bite his or her tongue
d) The patient may lose bowel and bladder control
2) Clonic
a) Body begins to jerk violently for as little as 1 or 2 minutes up to 5 minutes
b) Patient may have froth at his or her mouth and drool
c) Face and lips may show cyanosis because of the brief breathing cessation
3) Postictal (post-, or after the seizure; -tictal, referring to “blow” or “stroke”)
a) Patient may regain consciousness immediately but may be confused, or may
remain unconscious for several hours
b) Patient may feel sleepy and weak
c) Patient may have a headache
2. Myoclonic (myo- referring to muscle; -clonic referring to spasm)
a. Usually occur in children during their first 5 years
b. Patient shows brief jerking movement originating from the central nervous system
c. Seizures involve both sides of the body and may be subtle and barely noticeable or
very dramatic and obvious
d. May be thought of as clumsiness or a sudden unexplained jerk, as what happens
during sleep to a foot or leg
e. No first aid is required (but see Patient Care below), but after a first significant event,
the person should receive a medical evaluation
3. Absence or petit mal
a. Brief, lasting 1 to 10 seconds with no warning or aftereffect
b. Patient has temporary lapses of awareness or concentration, sometimes with staring
c. Patient has no major motor activity and the seizure usually goes unnoticed
d. Start between ages 4 and 12, rarely begin after age 20
e. The child may have 50 to 100 attacks a day
1) Interfere with the current thought activity
2) Interfere with learning
f. Often cease in adulthood, but may develop into tonic-clonic type seizures
g. No first aid is required (but see Patient Care below), but the child should have a
medical evaluation
4. Atonic, also called “drop attacks,” astatic, or akinetic seizures (“a” is a prefix for “no”—
referring to no muscle tone or rigidity; completely without muscle tension; flaccid)
a. Patient will have sudden head drop, loss of posture, or collapse
b. Seizure is abrupt without warning
c. Patient falls with force (drops), sustains injuries to head and face (patients who do
not respond to drug therapy may wear protective head gear)
d. After the first atonic seizure, patient should receive a medical evaluation
e. No first aid is required except to treat any injuries from the fall (and see Patient Care
below)
III.
Patient Care Procedures (based on Maryland Protocols): Students should demonstrate care in
role play scenarios
A. Initiate general patient care
1. Arrival and size-up
2. Patient approach
3. Initial assessment
a. Mental status
b. Airway
c. Breathing
d. Circulation
e. Disability
f. Exposure
g. Clinical priority (1, 2, 3, or 4)
h. Disposition (mode, status)
4. History and physical exam/assessment
a. What was the patient doing or how was the patient feeling before the seizure?
b. What did the patient’s seizures look like?
c. How long did the seizure last?
d. Did the patient lose bowel or bladder control?
e. How did the patient respond after the seizure (awake, sleep, able to answer
questions)?
f. What injuries did the patient sustain?
B. Treatment
1. Presentation
a. Seizures and a neuromuscular response to an underlying cause
1) Epilepsy
2) Hypoxia
3) Hypoglycemia
4) Hypoperfusion
5) Head injury
6) CVA
7) Alcohol or drug abuse
b. Consider recent history
1) Illness
2) Infection
3) Fever
4) Stiff neck
2. Patient care for adult and pediatric patients
a. If patient is still seizing
1) Position patient on his or her side (no indication of spine injury) for oral drainage
2) Do not try to force anything into the patient’s mouth
3) Do not restrain
4) Loosen restrictive clothing
5) Protect the patient from further injury
6) Consider cause of seizure activity
b. After the patient has stopped seizing
1) Identify and treat injuries
2) Suction the airway, if necessary
3) If the patient shows cyanosis, provide oxygen (12-15 lpm NRB or 2-6 lpm nasal
cannula—adults and peds)
4) If patient is diabetic, place glucose paste (10-15 grams) between the gum and
cheek (administer in small doses for pediatric patients)
5) Use the AVPU scale to assess mental status
6) Monitor vital signs and respirations
7) Encourage the patient to allow you to transport, especially if this is a first seizure,
even if the patient says he or she feels o.k.
Summary:
Student Performance Objective: Given information, resources, and opportunity for discussion and
practice, at the completion of this session, EMTs will be able to list causes, types, and signs and
symptoms of seizures, describe patient care procedures and demonstrate patient assessment and
care. EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for
Emergency Medical Providers.
Review:
 Causes of Seizures
– List causes by age group: 6 mos.-3 yrs., 2-14, after 25
– List 7 causes for any age group
 Types of Seizures and Their Signs and Symptoms
– Name two types of partial seizures; list signs and symptoms
– Name four types of general seizures; list signs and symptoms
 Patient Care Procedures
– List the skill steps demonstrated during practice in caring for seizure patients