Altered mental status SP suspected seizure part 2


• PTA – mom gave 2 doses of clonazepam po prior to arrival.
• Scene – Vitals, EKG
• En route – n/a
• Hospital – n/a


• Response to treatment – no changes.
• Disposition – Not transported. At home under parent supervision. Will call back for transport if any other seizures.


• Merlin Curry, MD Paramedic University of Arizona
• Elliot Williams, Paramedic Woodburn Ambulance
• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


• Craig Warden, MD Professor Oregon Health & Science University

• Seizure
• Epilepsy
• Postictal state

Differential Diagnosis

• Seizure
• Postictal state
• Illicit drug use
• Intoxication
• Closed head injury (concussion, intracranial bleed)
• Infection (eg, meningitis)
• Metabolic causes (diabetic ketoacidosis)

Patient Workup

• See additional video interviews in Supporting Materials, below
• Caregiver (mom) states this is the worst seizure the patient has ever had; lasted 5-6 minutes of whole body shaking, turned blue.
• Was witnessed by girlfriend, laying in bed when it happened.
• Mom states patient has been having “blips,” small periods where – during normal conversation – he will check out for a second.
• Mom states that these usually lead up to a larger seizure and then he “resets,” but that this is the worst seizure he has ever had. Mom states postictal lasts about 30 minutes before most orientation returns; takes about 1 hour to return to normal.

Physical Exam

• GCS 4/4/6 = 14
• CBG – 106
• Pupils – 3-4mm equal
• Atraumatic
• No incontinence

Editor’s Notes

What are the scenarios where transport is mandatory when teenagers present with altered mental status?

Standard Approach
Suggested Approach

• Evaluate mental status and ability to protect his airway. If needed, use a jaw-thrust to open the airway.
• Ensure adequate oxygenation and ventilation.
• Quickly check a finger-stick blood sugar and look for quickly-reversible causes, such as opiate overdose.
• Seizure is the most likely cause of this patient’s altered mental status, based on parents’ report. If this seizure represents a new or different pattern, or if mental status does not clear to baseline, consider transport to the hospital for further evaluation and observation.
• Lights and sirens for transport would be indicated if the patient was in status epilepticus, or had seizure complicated by trauma, airway compromise, or hemodynamic instability.


• This teenager presents with altered mental status, however is quickly clearing to normal (baseline).
• The postictal state is only one of many etiologies to consider (see DDx above).
• Obtain a complete seizure history that includes length and type of seizure, medications given that are routine or as-needed when seizures occur, and usual postictal course.
• Often a history of lack of sleep, drug/EtOH use or other stressor can be identified as a precipitant and may be important to communicate to medical staff.
• In this case the patient had a stable home environment with close observation, so it was safe to allow the patient to decline to be transported to the hospital. However, patients should still be offered transport for evaluation and should be encouraged to go to the hospital by ambulance if this is a first time seizure; if they are alone or do not have a way of calling for help; if the seizure today was markedly different or worse than normal, or if they have problems with taking their prescribed medications.
• If the patient’s mental status does not clear or he has persistent altered mental status, he may not be able to understand the risks and benefits of transport to the hospital, or seek help if he changes his mind. If the patient does not have decision-making capacity, transport is required. Contact online medical control for consultation and try to convince the patient to be evaluated. If the patient is under the legal age for medical decision making, is acutely agitated or combative, or if the cause of the altered mental status is unknown and they do not demonstrate decision making capacity, they may require physical and chemical restraint for safe transport. Please consult with your medical director and always follow your system protocols.

Suggested references

• [Pediatric Prehospital Seizure Management (


• Gender: Male
• Age: 17 years
• Height: Not Available
• Weight: Not Available


• Temperature: Not Available
• Blood Pressure: 130/78
• Heart Rate: 102
• Respiratory Rate: 14
• Pulse Oximetry: 98% RA

Signs and Symptoms

Confusion, disorientation following 5-minute seizure


• Epilepsy; high stress. Not allowed to take stairs at school or drive due to diagnosis.
• Dispatch info: 17yom unconscious, in active seizure.


• Lives with mom; graduating high school next day.


• Clonazepam, Keppra, lamotrigine, Onfi, B6

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