• Scene – chemical restraint, 2.5mg Versed x 2, physical restraint, vitals, cardiac monitor.
• En route – vitals, cardiac monitor.
• Hospital – not known
• Response to treatment – Pt became less combative, but still fought against restraints.
• Patient was evaluated and transferred to hospital.
• Eric Boyd, Paramedic Woodburn Ambulance
• Dan Limmer, AS, EMT-P Limmer Creative
• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Altered mental status
• Atypical seizure
• Postictal state
• Organic brain syndrome
• Drug or alcohol use
• Medication overdose (Ambien adverse effect).
• Caregiver states – Pt’s wife states pt was hospitalized multiple times for possible strokes.
• Pt has been diagnosed with periodic lateralized epileptiform discharges (PLEDs) on EEG.
• Pt had a migraine yesterday that was did not go away with Tylenol. He took an Ambien at bed time and woke up with the same migraine.
• Wife states that this afternoon pt started holding his head and acting confused.
• Wife states this is the same as past episodes.
• Wife states the migraines do not always precede a seizure.
• Wife states that pt’s last seizure was one year ago in June.
• Physical findings – no signs of trauma noted.
• Pt was CAO to self only. Pt stated “I don’t know anything” when asked questions.
• Pt did not show any signs of hemiparesis, slurred speech, or facial droop.
• Pt was able to ambulate without assistance.
• Pt became very combative and withdrew from all interventions; pt started swinging and trying to bite responders.
• When communicating with pt it appeared that he had no connection with reality and current events.
• When attempting to assist pt to the stretcher pt withdrew and moved away.
• GCS – 4-4-6
• EKG – A-fib
• CBG – 88mg/dcl
I believe the strength in this video is the potential for differential diagnosis of the altered mental status patient. He has a past history many in EMS won’t be familiar with. He also has a headache and mental status changes that would make many consider stroke (as it appears has been done in the past). With the apparent inability to do a stroke scale because of patient compliance issues it would seem that EMS personnel should observe for facial asymmetry and slurred speech in an attempt to R/O stroke. This is noted in the physical exam section. Hypertension increases his risk of stroke. -Dan Limmer, AS, EMT-P
This patient clearly has altered mental status (AMS). He may be in a postictal state, or his AMS may be a non-convulsive seizure event. Based on previous events, his wife is concerned that he will become violent. Scene safety is paramount for the patient and emergency medical provider. How would you handle this transport? -Dr. David S
Recognizing and defusing aggressive patients
Assessing mental status
• Gender: Male
• Age: 78 years
• Height: Not Available
• Temperature: Not Available
• Blood Pressure: 180/110
• Heart Rate: 110
• Respiratory Rate: 20
• Pulse Oximetry: 99% RA
Signs and Symptoms
Confusion, aggression, headache, altered mental status.
• PMH: seizures, a-fib, hypertension, periodic lateralized epileptiform discharges (PLEDs).
• Allergies: none
• Dispatch info: 78 y/o with Hx of seizure; not shaking, but in seizure per wife.
• Pt is retired and travels with his wife in a travel trailer. Wife states pt does not use alcohol or tobacco.
• Warfarin, lisinopril, Ambien