What could be the cause of a patient (pt) becoming combative post-seizures?

From the Guidelines

Post-seizure combativeness is most likely caused by postictal confusion, which occurs as the brain recovers from the electrical storm of a seizure, leading to disorientation and agitation, as supported by the latest clinical policy from 2024 1. This condition can be exacerbated by various factors, including:

• Hypoxia during the seizure, which can worsen confusion and combative behavior
• Postictal psychosis, characterized by hallucinations or delusions that trigger aggressive responses
• Underlying psychiatric conditions, which can worsen during the postictal period
• Physical discomfort, such as headache, muscle pain, or urinary incontinence, contributing to irritability Management of post-seizure combativeness should focus on:
• Ensuring patient safety in a calm environment
• Avoiding restraints when possible
• Administering benzodiazepines, like lorazepam 1-2mg IV/IM, if necessary, as recommended by the American College of Emergency Physicians 1
• Treating any underlying causes
• Speaking calmly, orienting the patient, and allowing recovery time It is essential to note that most postictal aggression resolves spontaneously as the brain returns to normal function, typically within minutes to hours, but persistent combativeness warrants further neurological evaluation to rule out status epilepticus or other serious conditions, as highlighted in the clinical policy from 2014 1.

From the FDA Drug Label

Reactions such as agitation, involuntary movements (including tonic/clonic movements and muscle tremor), hyperactivity and combativeness have been reported in both adult and pediatric patients These reactions may be due to inadequate or excessive dosing or improper administration of midazolam; however, consideration should be given to the possibility of cerebral hypoxia or true paradoxical reactions.

The cause of a patient becoming combative post-seizures could be due to inadequate or excessive dosing of midazolam, improper administration, cerebral hypoxia, or true paradoxical reactions 2.

• Cerebral hypoxia may occur due to respiratory depression, airway obstruction, or apnea.
• Paradoxical reactions can occur with benzodiazepines, including midazolam, and may manifest as agitation, hyperactivity, or combativeness. It is essential to monitor patients closely for these adverse reactions and adjust the dosage or administration of midazolam accordingly.

From the Research

Possible Causes of Combative Behavior Post-Seizures

• Post-ictal agitation or confusion, which can be caused by the seizure itself or by the underlying neurological condition 3
• Medication side effects, such as those caused by benzodiazepines, which can have paradoxical effects in some individuals 3, 4
• Underlying psychiatric or neurological conditions, such as schizophrenia or epilepsy, which can increase the risk of agitation or combative behavior 5

Factors Influencing Combative Behavior

• The type and severity of the seizure, with more severe seizures potentially leading to more pronounced post-ictal agitation 3
• The individual's medical history and underlying conditions, which can affect their response to seizures and medications 5
• The use of certain medications, such as benzodiazepines, which can have varying effects on different individuals 3, 4

Management of Combative Behavior

• The use of pharmacological interventions, such as midazolam, olanzapine, or haloperidol, to manage acute agitation 6, 7, 4
• The importance of considering the individual's medical history and underlying conditions when selecting a treatment approach 5
• The need for careful monitoring and assessment of the individual's response to treatment, in order to minimize the risk of adverse effects 6, 7, 4