Neurology: Seizures, Confusion, Headache and Fainting
Seizures, altered mental status, headache, syncope, and dementia versus delirium
The brain needs a steady supply of oxygen and sugar, and it shows trouble in a few ways: shaking, confusion, pain, or a sudden drop to the floor. You will not find the exact cause in the field. You can protect the airway, find what is fixable, and tell the hospital a clear story with times in it.
Seizures
In a generalized seizure the patient goes stiff, then jerks all over, often with a bitten tongue and lost bladder control. While it is happening, move objects away, cushion the head, and time it. Do not hold the patient down and do not put anything in the mouth. When the jerking stops, roll the patient to the side, suction as needed and give oxygen. The sleepy, confused period afterward is the postictal state. It is expected, and it clears gradually.
A seizure that lasts more than about five minutes, or seizures that repeat without the patient waking between them, is status epilepticus. That is a life threat. Manage the airway, ventilate if breathing is inadequate, and call for ALS, who carry the drugs that stop it. Common causes of any seizure are missed seizure medication, low blood sugar, head injury, stroke, poisoning, alcohol withdrawal, and fever in a young child.
Altered mental status
Altered mental status is a sign, not a diagnosis. The list of causes is long: low oxygen, low blood sugar, stroke, seizure, overdose, infection, head injury, and alcohol. Alcohol on the breath does not rule out any of the others, so never assume a confused patient is only drunk. Work it the same way every time: airway, breathing, oxygen if needed, then look for medical causes such as low blood sugar, stroke or head injury. If you suspect stroke, use a named scale such as the Cincinnati Prehospital Stroke Scale (facial droop, arm drift, abnormal speech), and find out the time the patient was last known well. That time decides which treatments the hospital can offer.
Headache
Most headaches are not emergencies. These findings change that:
- A sudden, severe headache described as the worst of the patient's life, which suggests bleeding in or around the brain.
- Headache with fever and a stiff neck, which suggests meningitis. Put a mask on yourself and the patient.
- Headache with weakness, vision loss, trouble speaking or confusion.
- Headache after a head injury, or with a very high blood pressure.
Syncope
Syncope is a brief loss of consciousness from a drop in blood flow to the brain, with a quick and full recovery. A simple faint usually has a trigger and a warning: standing in the heat, pain, the sight of blood, then lightheadedness and tunnel vision. Fainting that comes from the heart looks different. Be worried when it happens during exertion, with no warning, with palpitations or chest pain, or in an older patient. Check for injuries from the fall, take vital signs, and transport. A patient who is not back to normal within a few minutes did not simply faint.
Dementia versus delirium
Dementia comes on slowly over months to years and stays fairly steady from day to day. Delirium comes on suddenly, over hours to days. It rises and falls, the patient cannot hold attention, and may see things that are not there. Delirium has a medical cause, often an infection such as a urinary infection in an older adult, a medication, low oxygen or low blood sugar, and it is often reversible. A patient with dementia can also develop delirium. Ask the caregiver two questions: is this normal for them, and when did it change?
Confusion always has a cause. A sudden change in thinking is a medical emergency until proven otherwise, at any age and with or without alcohol on the breath.
Which stroke scale you use, whether you check blood glucose, and where stroke patients go are set by your local protocols and your medical director. They govern real practice.