What is an appropriate nursing action when a child is experiencing a generalized tonic clonic seizure?

Seizure - tonic-clonic; Seizure - grand mal; Grand mal seizure; Seizure - generalized; Epilepsy - generalized seizure

Generalized tonic-clonic seizure is a type of seizure that involves the entire body. It is also called grand mal seizure. The terms seizure, convulsion, or epilepsy are most often associated with generalized tonic-clonic seizures.

The major areas of the brain have one or more specific functions.

1. When a seizure occurs, the main goal is to protect the person from injury. Try to prevent a fall by laying the person on the ground in a safe area. The area should be cleared of furniture or other sharp objects. 2. Cushion the person's head. 3. Loosen tight clothing, especially around the neck.

Seizures result from overactivity in the brain. Generalized tonic-clonic seizures may occur in people of any age. They can occur once (single episode). Or, they can occur as part of a repeated, chronic illness (epilepsy). Some seizures are due to psychological problems (psychogenic).

Having a brain seizure can be a terrifying experience. If you have a seizure more than once, you may have epilepsy, a problem with electrical activity in your brain. So, what causes epilepsy? For most people, the brain sends electrical signals throughout the body efficiently, in a coordinated way. In epilepsy, however, the normal pattern of electrical activity becomes disturbed. This causes the brain to be too excitable, or jumpy, and it sends out abnormal signals. The result is repeated seizures that can happen at any time. Epilepsy seizures usually begin between ages 5 and 20, but they can happen at any age. Common causes include Stroke, or a mini-stroke called transient ischemic attack; Dementia, or loss of brain function, such as Alzheimer's disease; Traumatic brain injury; Infections in the brain; Brain problems you are born with; or perhaps, a Brain tumor. Some people with epilepsy may have simple staring spells, while others have violent, uncontrollable shaking and loss of consciousness. Before each seizure, some people may have strange sensations, such as tingling, smelling an odor that isn't really there, or emotional changes. This is called an aura. Your doctor will perform a number of tests to find out if epilepsy is causing your seizures. One test, an electroencephalogram or EEG, checks your brain's electrical activity. Other tests can take detailed pictures of the part of your brain that is causing your seizures. Your doctor will most likely start treating your epilepsy with medication. These medicines, called anticonvulsants, may reduce the number of seizures you have in the future. Sometimes, changing the diet of a child with epilepsy can help prevent seizures. Your doctor will probably talk to you about making some changes in your life, such as reducing your stress, getting more sleep, and avoiding alcohol and recreational drugs. Surgery to remove a brain tumor or abnormal blood vessels or brain cells may make the seizures stop. Another surgery can place a Vagus nerve stimulator in your brain. This device is like a pacemaker for your brain that limits the number of seizures you have. For many people, epilepsy is a lifelong problem, and they'll always need to take anti-seizure medicines. There is a very low risk of sudden death with epilepsy. However, you, or someone else, can be seriously injured if you have a seizure while driving or operating equipment. If your seizures are uncontrolled, you should not drive.

Many people with generalized tonic-clonic seizures have vision, taste, smell, or sensory changes, hallucinations, or dizziness before the seizure. This is called an aura.

The seizures often result in rigid muscles. This is followed by violent muscle contractions and loss of alertness (consciousness). Other symptoms that occur during the seizure may include:

After the seizure, the person may have:

• Confusion
• Drowsiness or sleepiness that lasts for 1 hour or longer (called the post-ictal state)
• Loss of memory (amnesia) about the seizure episode
• Headache
• Weakness of 1 side of the body for a few minutes to a few hours following seizure (called Todd paralysis)

The doctor will perform a physical exam. This will include a detailed check of the brain and nervous system.

An EEG (electroencephalogram) will be done to check the electrical activity in the brain. People with seizures often have abnormal electrical activity seen on this test. In some cases, the test shows the area in the brain where the seizures start. The brain may appear normal after a seizure or between seizures.

Blood tests may also be ordered to check for other health problems that may be causing the seizures.

Head CT or MRI scan may be done to find the cause and location of the problem in the brain.

Treatment for tonic-clonic seizures includes medicines, changes in lifestyle for adults and children, such as activity and diet, and sometimes surgery. Your doctor can tell you more about these options.

Abou-Khalil BW, Gallagher MJ, Macdonald RL. Epilepsies. In: Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL, eds. Bradley's Neurology in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016:chap 101.

Leach JP, Davenport RJ. Neurology. In: Ralston SH, Penman ID, Strachan MWJ, Hobson RP, eds. Davidson's Principles and Practice of Medicine. 23rd ed. Philadelphia, PA: Elsevier; 2018:chap 25.

Thijs RD, Surges R, O'Brien TJ, Sander JW. Epilepsy in adults. Lancet. 2019;393(10172):689-701. PMID: 30686584 pubmed.ncbi.nlm.nih.gov/30686584/.

Wiebe S. The epilepsies. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 375.

Last reviewed on: 2/4/2020

Reviewed by: Amit M. Shelat, DO, FACP, FAAN, Attending Neurologist and Assistant Professor of Clinical Neurology, Stony Brook University School of Medicine, Stony Brook, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

When most people think of a seizure, they think of a generalized tonic-clonic seizure, also called a grand mal seizure. In this type of seizure, the person may cry out, fall, shake or jerk, and become unaware of what’s going on around them.

Here are things you can do to help someone who is having this type of seizure:

• Ease the person to the floor.
• Turn the person gently onto one side. This will help the person breathe.
• Clear the area around the person of anything hard or sharp. This can prevent injury.
• Put something soft and flat, like a folded jacket, under his or her head.
• Remove eyeglasses.
• Loosen ties or anything around the neck that may make it hard to breathe.
• Time the seizure. Call 911 if the seizure lasts longer than 5 minutes.

Epilepsy is a common condition of the brain in which a person tends to have recurrent unprovoked seizures.

About 70% of people with epilepsy gain control of their seizures with medication. People who continue to have seizures are more vulnerable to the potential risks associated with seizures, especially when seizures occur without warning and impair awareness.

Epilepsy, like other long-term conditions such as asthma or diabetes, comes with certain risks. If left unchecked these can become very serious.

Seizure-related risks are higher when people have poorly controlled seizures. Good seizure control is the first step in reducing seizure-related risks.

Seizures can sometimes lead to injuries or falls, and they can occasionally be more serious – even contributing to, or causing, death. Different types of seizures carry different risks.

Your risk level depends on the type of seizures you have, and your lifestyle. For instance, poorly controlled tonic-clonic seizures pose the highest safety risk, and if you take part in activities such as mountain climbing, this risk is increased.

Life is never risk-free, but taking positive action to reduce your seizures, thinking about risks specific to you and discussing seizure management with your doctor are a start to reducing some of your seizure-related risks.

Epileptic seizure first aid

If you are with someone having a tonic-clonic seizure (where the body stiffens, followed by general muscle jerking), try to:

• Stay calm and remain with the person.
• If they have food or fluid in their mouth, roll them onto their side immediately.
• Keep them safe and protect them from injury.
• Place something soft under their head and loosen any tight clothing.
• Reassure the person until they recover.
• Time the seizure, if you can.
• Gently roll the person onto their side after the jerking stops.

Do not put anything into their mouth or restrain or move the person, unless they are in danger.

Epilepsy Smart Australia have produced a Seizure first aid information sheet showing what to do if someone has a seizure.

If a person having a seizure is in a wheelchair

If a person has a seizure when they are in a wheelchair, car seat or stroller:

• Leave the person seated with the seatbelt on (unless it is causing injury).
• Put the wheelchair brakes on.
• If it’s a tilt wheelchair, tilt the seat and lock in position.
• Support their head until the seizure has ended.
• Lean the person slightly to one side to aid drainage of any fluid in the mouth.

After the seizure, if the person is having trouble breathing or they need to sleep, take them out of the chair and put them in the recovery position.

If their breathing difficulties continue, call an ambulance and closely monitor the person. Be prepared to perform CPR if they stop breathing.

Be aware that the CPR technique for adults is different to the CPR technique for young children and infants .

Seizures in water

If a seizure occurs in water:

• Support the person's head so their face is out of the water.
• Tilt their head back to ensure a clear airway.
• If the person is in a pool, remove them from the water when the jerking stops.Note: In the rare circumstance the jerking does not stop, seek help from others if possible, and remove the person from the water at the shallowest end of the pool.
• If the person is in the surf, remove them from the water immediately.
• Flotation devices may be useful when removing someone from water.
• Seek help if possible.

Once out of the water:

• Call triple zero (000) for an ambulance immediately. (Do this even if the person is breathing, as they may have inhaled water)
• Place the person on their side.
• Check to see if they are breathing.
• If they are not breathing, or they are not breathing normally, reposition the person onto their back and begin the appropriate form of CPR: CPR for adults is different to the CPR for young children and infants .

When to call an ambulance for an epileptic seizure

Call triple zero (000) for an ambulance if:

• the seizure lasts for 5 or more minutes or longer than what is normal for the person
• a second seizure quickly follows
• the person is not responding for more than 5 minutes after the seizure ends
• the person has breathing difficulties after the jerking stops
• it is the person’s first known seizure
• the seizure occurs in water
• the person is injured
• you are in doubt.

Epilepsy and your safety

Anything that affects a person’s conscious state, awareness or judgement can increase the risk of accidents.

If you have a seizure, your doctor will advise you in relation to driving, the use of dangerous machinery, working above ground level and general safety issues.

Some people choose to wear a specially designed medical alert bracelet or pendant with epilepsy information, in case of an accident. Another option is to carry medical information in your wallet.

Epilepsy and driving

Seizures can affect your ability to drive safely.

If you have a seizure or are diagnosed with epilepsy, your doctor will inform you that you cannot drive. How long this period will last will depend on many things including:

• what caused the seizure
• what type of seizure you had
• if it is epilepsy, and if so, what type of epilepsy.

If you meet certain criteria later on, you will be able to drive again – safely and legally. If you do not meet those criteria, your licence may not be renewed, or you may be issued a conditional licence.

It’s your responsibility to inform the driving authorities about having epilepsy or a seizure. In Victoria, this means informing VicRoads.

Driving against medical advice is illegal and dangerous to you, your passengers and the general public. There are many safety factors to consider as seizures often occur without warning.

If you continue to drive and are involved in a motor vehicle accident during the recommended non-driving period, and it’s found that a seizure was a contributing factor, you may be prosecuted and charged or even jailed.

Learn more about seizures and driving in Victoria .

Epilepsy and water safety

If a seizure happens in water, it can lead to a life threatening situation. It’s important to think about water safety, recognise risks and what steps to take if a seizure may happen in the water.

Some simple suggestions include:

• Never swim alone.
• Wear an approved life jacket for water activities, including boating and fishing.
• Avoid water sports such as scuba and high board diving.
• Have a shower rather than a bath, as showers pose less risk. If you only have a bath, use a hand-held shower attachment.
• Do not shower or bathe while alone in the house, if possible.
• Shower at a time when seizures are less likely to happen.
• Preferably have outward opening doors, sliding doors, half doors or doors that are easily removable fitted to the bathrooms.
• Keep bathroom doors unlocked.

Epilepsy and general hazards

People take risks every day, but people who have seizures may have to deal with different risks. By becoming aware of potential risks and ways these can be lessened, activities can be safer and most people with epilepsy can live full and active lives.

Injuries and accidents tend to occur more around the home than anywhere else. There are many ways you can make your home safer. Try doing a few things like:

• Arrange your home and, if possible, other areas such as your work or study space to be safe in the event you have a seizure. For example:
  • pad any sharp corners
  • use non-slip flooring
  • always have good barriers in front of fireplaces or heaters
  • have a door that opens both ways into your bathroom and toilet.
• If you wander or are confused during or after a seizure:
  • pay special attention to heights, railings, stairs, swimming pools and other bodies of water
  • shut your door when you are home alone, so you are less likely to wander outside or into dangerous areas
  • make sure someone else has a key to get in and check on you
  • consider wearing some form of medical ID.
• If you are likely to fall during seizures, ‘fall-proof’ your home and other areas as much as possible. Put in carpets, cover sharp corners, and avoid glass tables and shower screens.
• Consider wearing a protective helmet if you have frequent falls. There are helmets designed as casual wear that you can buy.

Keep your safety precautions sensible and relevant, with a balance between risk and restrictions. Enjoy life as much as you can and don’t restrict activities to a point where you exclude interest and fun.

Take the time to think about your home, work and leisure activities. What may be potential dangers if a seizure occurs? How can you reduce the risk of harm to yourself or others?

There are many practical ways you can easily improve the safety of your environment. For example, take a look at Epilepsy Action Australia’s safety checklist .

Seizure emergencies

Most seizures last less than 2 minutes. However, some people with epilepsy tend to have severe or life-threatening seizures. For these people, seizures may be prolonged or happen in clusters. In some people these severe seizures can happen regularly.

These situations are considered seizure emergencies. They can lead to brain injury and can be life threatening, so it’s important to recognise and treat these seizures quickly.

Fortunately, it’s possible to administer out-of-hospital medication in a way that is likely to stop a severe seizure. This medication can be prescribed by your neurologist.

Sudden unexpected death in epilepsy (SUDEP)

Sudden Unexpected Death in Epilepsy (SUDEP) is when a person with epilepsy dies suddenly and prematurely and no reason for death is found.

SUDEP deaths are often unwitnessed, with many of the deaths occurring overnight. There may be obvious signs a seizure has happened, though this isn’t always the case.

The cause of SUDEP is not yet known. Researchers are investigating a range of possibilities such as the effect of seizures on breathing and the heart.

SUDEP occurs in approximately 1 in 1000 people with epilepsy (1 in 4,500 children).

Having active or poorly controlled seizures can put you at risk of injury and death. Research has shown that there are certain types of seizure that increase your risk of SUDEP. Ask your doctor for more information about SUDEP or get a SUDEP and Safety Checklist done by your doctor or epilepsy nurse.

Reducing the risks of SUDEP

Knowing about epilepsy-related risks of injury and death means you can act against them. Steps you can take to reduce seizure-related risks, injury or death are:

• Get the best seizure control possible.
  • Take your medication as prescribed.
  • Speak to your doctor if you’re not happy with your current medication or side effects.
  • Have regular reviews with your doctor.
• Be involved in self-management.
  • Avoid any known seizure triggers for you.
  • Avoid drinking too much alcohol.
  • Know when your seizures are most likely to occur.
  • Get enough sleep.
  • Be healthy.
  • Manage stress.
• Make sure those close to you know what to do in case of a seizure.

Where to get help