Generalized Seizures

TONIC-CLONIC (GRAND MAL)

Tonic-clonic seizures (older terms: grand mal seizures or convulsions) are the most recognized type of seizure. There are two parts to a tonic-clonic seizure: the tonic phase, which is the stiffening of the body and limbs; and the clonic phase, which is the jerking or convulsing of the body. A tonic-clonic seizure typically lasts 2 to 3 minutes. This seizure is sometimes confused with a heart attack or stroke.

During the seizure, a person may:

• Cry out and fall
• Go rigid
• Lose consciousness
• Begin shaking and rapidly jerk their muscles
• Have trouble breathing
• Bite their tongue or inside of their cheek
• Lose bladder or bowel control

After the seizure, the person:

• May not become fully conscious right away (if it takes more than 30 minutes, they may need to go to the ER)
• May appear confused, tired, or have a headache
• May sleep for several minutes or hours
• Breathes normally and eventually becomes fully conscious

FIRST AID

DO

• Stay calm
• Time the seizure
• Turn the person on their side to keep their airway clear, unless they have an injury
• Protect their head with your hands or a soft object
• Protect them from nearby hazards
• Loosen tight clothing around the neck like ties and collars
• Call an ambulance if the seizure lasts longer than 5 minutes, it is the person’s first seizure, the person is pregnant, or has diabetes
• Keep onlookers away and explain what is happening
• Stay with the person until the seizure is over and consciousness has fully returned

DON’T

• Put any object in the mouth or try to hold the tongue
• Restrain the person or hold them down
• Give liquids or oral medications until conscious
• Use artificial respiration during the seizure

ABSENCE (PETIT MAL)

Absence seizures (older terms: petit mal seizures or staring spells) are a brief loss of awareness causing a person, most commonly children, to stare into space. The seizure usually lasts 5 to 10 seconds and can be easily missed. Absence seizures often happen many times during the day. This type of seizure may be confused with daydreaming or lack of attention.

During the seizure, a person may:

• Stare blankly
• Blink quickly
• Make chewing movements
• Have a glazed look on their face
• Not respond if they are called or touched
• Be unaware of what’s going on around them
• Other symptoms may include: hand gestures, eye fluttering, eye rolling, or a slight facial twitch

After the seizure, the person:

• Becomes fully conscious right away

FIRST AID

• No immediate first aid necessary

DO

• Try to document duration of the seizure
• Give comfort and reassurance
• Time the seizures if they begin to cluster
• Help the person reintegrate into the task they were just doing

ATONIC SEIZURES (DROP ATTACKS)

Atonic seizures (older term: drop attacks) are a sudden loss of muscle tone, causing the person to fall to the ground or slump over in a chair. This seizure occurs suddenly and with no warning; and the person is not able to react, resulting in possible injuries to the head and face from a fall. The seizure usually lasts 10-60 seconds and is sometimes confused with being clumsy, poor walking skills, or being drunk.

During the seizure, a person may:

• Suddenly lose muscle control or suddenly fall
• Lose consciousness

After the seizure, the person:

• Becomes fully conscious
• Can stand and walk
• May be sore or injured from the fall and need first aid

FIRST AID

• No first aid needed unless the person is hurt during a fall

DO

• Provide emotional support and reassurance

MYOCLONIC SEIZURES

Myoclonic seizures are sudden, brief, massive muscle jerks that may involve the whole body or parts of the body. The seizure lasts only a few seconds and the person maintains consciousness throughout. Myoclonic seizures can often occur in conjunction with various epilepsy syndromes. This seizure is sometimes confused with clumsiness or poor coordination.

During the seizure, a person may:

• Suddenly jerk their whole body or part of their body
• Spill a drink, drop an object, or fall off of a chair
• Maintain consciousness

After the seizure, the person:

• May be sore or injured from the fall and need first aid

FIRST AID

• No first aid needed unless injury occurs

DO

• Provide emotional support and reassurance

INFANTILE SPASMS

Infantile spasms are myoclonic seizures in young children 3 to 24 months old. This seizure is sometimes confused with the child asking to be held or colic.

During the seizure, a child may:

• Move their body suddenly
• Let their head and arms fall forward
• Fold up their knees and lift up their arms and head

FIRST AID

• Take the baby to the doctor or emergency department if this is the first time

• Document the duration of the seizure

Febrile Seizures

Febrile seizures are seizures that occur as a result of a high fever. These typically occur in children under 5 years of age and generally last anywhere from a few seconds to a few minutes. Febrile seizures are not necessarily indicative of a diagnosis of epilepsy, but they can be just as scary as epileptic seizures. If this is the first time your child is having a febrile seizure, they should be transported to an emergency room for evaluation; from there, the physician will provide instructions on how to move forward if your child experiences another febrile seizure.

Even though febrile seizures do not necessarily constitute a diagnosis of epilepsy, the first aid procedures are the same for tonic-clonic seizures.

Focal Seizures

FOCAL WITHOUT ALTERED AWARENESS, FOCAL AWARE (SIMPLE PARTIAL)

Focal without altered awareness (older term: simple partial) seizures do not cause loss of awareness. The person is awake and alert but may not be able to speak or move until after the seizure is over. People may also refer to this type of seizure as an aura. They typically last 1 to 2 minutes and may progress to become a tonic-clonic seizure. This seizure is sometimes confused with acting out, hysteria, mental illness, mystical experiences, or psychosomatic illness.

During the seizure, a person may:

• Jerk their body, arm, leg, or face
• Experience a distorted environment
• See or hear things that aren’t there
• Feel scared, sad, angry, or happy for no reason
• Have nausea, sense odd smells, or have a funny feeling in the stomach
• Feel like vomiting or have a stomach ache

After the seizure, the person:

• May need to rest

DO

• Stay calm
• Time the seizure
• Protect the person from harm
• Keep onlookers away and explain what is happening
• Stay with the person and support them when the seizure ends
• If the seizure becomes convulsive, then first aid is required as described for generalized tonic-clonic seizures above

FOCAL WITH ALTERED AWARENESS, FOCAL IMPARED AWARENESS (COMPLEX PARTIAL)

Focal with altered awareness (older term: complex partial) seizures will change a person’s awareness. The seizure may start with a blank stare, followed by repeated movements (called automatisms). Once a pattern is established, the same set of actions usually occur with each seizure. These seizures typically last 1 to 2 minutes, but post-seizure confusion can last substantially longer. When it is over, the person will not remember what happened during the seizure. These seizures may progress to become a tonic-clonic seizure. This seizure is sometimes confused with drunkenness, drug use, mental illness, disorderly conduct, or acting out.

During the seizure, a person may:

• Stare blankly
• Make chewing movements
• Move their body in unusual ways
• Not answer questions
• Be unaware, seem dazed
• Pick at clothing or try to take off their clothes
• Seem scared or confused
• Run, pick up objects, or mumble
• Struggle or flail at restraint

After the seizure, the person:

• Is confused
• Can’t remember what happened

DO

• Stay calm
• Time the seizure
• Guide away from obvious hazards (like stairs or traffic)
• Speak calmly and reassuringly to person
• Keep onlookers away and explain what is happening
• Stay with the person and support them when it’s over
• If the seizure becomes convulsive, then first aid is required as described for generalized tonic-clonic seizures above

DON’T

• Grab the person, unless there is sudden danger such as a cliff or an approaching car
• Try to restrain
• Shout

PSYCHOGENIC NON-EPILEPTIC SEIZURES (PNES)

Psychogenic non-epileptic seizures (PNES) are sudden, disruptive changes in a person’s behavior which resemble epileptic seizures but no electrophysiological changes in the brain are seen (does not show on an EEG). These events may be related to physical illness, or a psychiatric or emotional disorder. They are sometimes referred to as pseudoseizures.

While epileptic seizures can occur at any time and any place, most psychogenic seizures occur only during the daytime with observers present. Prolonged seizures are often common with psychogenic seizures, as are bizarre behaviors before, during, and after the seizure has occurred.

How a convulsive PNES seizure is different:

• Typically there is no tongue biting, or if there is, it is usually the tip of the tongue rather than the side
• Incontinence is extremely uncommon
• Significant injury is extremely uncommon

How a non-convulsive PNES seizure is different:

• Eyes are typically fully closed, and person is resistant to passive eye opening
• Automatisms are typically absent
• Moaning and crying may occur

FIRST AID

• Psychogenic seizures have the same first aid protocol as epileptic seizures and should be treated as such in the moment.
• Treatment methods outside of the seizure itself will vary, as psychogenic seizures do not typically respond to anti-epileptic drugs (AEDs) and other treatments that are typical for those diagnosed with epilepsy.

Status Epilepticus and Seizure Clusters

When seizures do not stop on their own, or when seizures occur in clusters without any recovery period in between, the person having the seizures is said to be in “status epilepticus.” This state of continuous seizure can be a serious medical emergency. Emergency treatments for status epilepticus may differ from patient to patient, based on directions given by their physicians. However, if you do not know the person who is having the seizures and if you are not familiar with the specifics of that emergency treatment recommended by the person’s physician, or if this is the first time a person has gone into status, call an ambulance and seek emergency care for the person.

Rescue Medications

If a person has seizures that last a long time, do not typically stop on their own, or tend to cluster, the doctor may prescribe a rescue medication. The doctor will give specific instructions on when and how to administer the emergency medication. Using these treatments may help to avoid trips to the emergency room. Rescue medications are prescribed as a precautionary measure, and are seldom actually needed.

• Diastat Accudial (diazepam rectal gel) — Diastat is a unique gel formulation of diazepam (valium) that is given rectally to stop a seizure or cluster of seizures. It was developed with families and non-medical personnel in mind, making it as easy as possible to administer.
• Versed (intranasal midazolam) — Versed is delivered by nasal spray. It allows for easy and safe administration of medication that is less invasive for the patient than rectal diazepam.
• Ativan (lorazepam) or Klonopin (clonazepam) — Ativan and Klonopin are oral medications given as a pill or tablet placed underneath the tongue or between the cheek and tongue where it will dissolve. Typically prescribed for people with cluster seizures or focal seizures.

NOTE: In most public schools, only the school nurse is permitted to administer these rescue medications. Additionally, schools and other child care centers are not necessarily required to administer them at all. If these facilities or individuals call EMS, paramedics will not administer medications prescribed to the individual. Instead, they are required by law to administer only medications from their supply.