Cause of combativeness after seizures

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DieselBolus17

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Hi all,

Had a pt. yesterday, 49 y/o female. Per witness on scene, pt tripped and fell and hit her forehead against floor (bare concrete). Pt. then had a grand mal seizure that lasted about 30 seconds. After seizure activity stopped, pt. was conscious (awake) but unresponsive, would not acknowledge/respond to anyone in the room. Pt. was also very combative. They stated pt. has a hx of anxiety and depression, but no seizure hx to their knowledge. Had a significant laceration to her forehead w/ blood all over the floor and bed. I sedated this pt. due to combative state and took her to a trauma center for a possible head injury. However, due to the MOI, I do not think that a head injury is the culprit, I think she probably seized prior to falling. I have never seen a combative pt. in a postical state however, wondering if you guys have seen it, and if so, what is the pathophysiology of combativeness during a postical period? Thanks in advance.
 
Patients being combative in a postictal state does happen and it's entirely possible that was the cause. I'm on my phone right now so I can't look up the pathophysiology right now, but the basic premise is the deprivation of oxygen to the brain produces an altered state and can put the person having the seizure into a fight or flight response as that is the only level of function that is working at that moment. Also based on the story a head injury is a strong possibility as hitting the head on bare concrete with enough force could have caused the patient to have the seizure
 
Hypoxia

I've had a decent number of combative patients after seizures.
 
Hypoxia might contribute in some cases, but I think it is a lot more complex than that. Even people with complex motor seizures that never stop breathing adequately during the seizure can have profound post-ictal symptoms.
 
Confusion, often including an element of combativeness, is de rigueur in the post ictal state.
 
What I wonder about is what determines whether people are combative in a post-ictal state. Is combativeness the result of some specific pathology, or is it just that some people get aggressive when they're confused? Is it personality-dependent?
 
My guess is that as the brain "resets" it starts with the lower level functions first (fight and flight response" before higher level thoughts (reasoning) start to function.
 
Acute postictal confusion and violence: Two cases with unfortunate outcomes

Just disorientation, most likely, as different sensory and processing abilities come back online at different rates.

"One can speculate that the typical postictal state of confusion and disorientation is the behavioral result of incomplete recovery of both self-identity and short- and long-term memories. Less common postictal behaviors, such as those of the two patients described here, may represent primitive human behavior patterns released or disinhibited by postictal suppression of normal executive functions. The first patient demonstrated a profound drive for “flight” – to escape confinement – while the second patient appeared to demonstrate primitive “fight” reflexes including both verbal and motor components. Taken together, these two cases illustrate that the postictal state can pose a much greater risk of harm to the patients themselves than to those around them."​
 
Meursault said:
What I wonder about is what determines whether people are combative in a post-ictal state. Is combativeness the result of some specific pathology, or is it just that some people get aggressive when they're confused? Is it personality-dependent?
Click to expand...

You mean like, what makes one person flail and another act stuporous? Does it tend to be consistent for certain patients? Not sure that's been looked at. Would be a fun study.
 
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