Generalized tonic-clonic (grand mal) seizures are convulsive seizures. They can be frightening to watch. The person loses consciousness, falls, stiffens (the tonic portion of the seizure), and jerks (the clonic portion of the seizure). Although a convulsive seizure appears painful, the person is not conscious during the seizure and therefore is unaware of what is happening. After the seizure, however, there may be discomfort caused by tongue biting, muscle soreness, headache, or bruises from falling. The seizure is often followed by confusion and tiredness, in what is called the postictal period. These seizures usually last less than 3 minutes, but the time can seem like an eternity to family members or friends who are watching it.

Seizures may cause bruises, cuts, sprains, or a bitten tongue, and they rarely cause broken or dislocated bones or other more serious problems. People who spend time with someone who is at risk of tonic-clonic seizures should learn first-aid guidelines:

• Stay calm. Anxiety and fear are not helpful. Easy to say, hard to do.
• Help the person lie down, and place something soft under the head and neck. Keep the person (especially the head) away from sharp or hard objects such as the corner of a table.
• Time the duration of convulsive movements, if possible.
• Roll the person onto one side with the head and mouth angled toward the ground so that any excessive saliva or fluids will not accidentally be swallowed or inhaled. This position will also prevent the tongue from falling back and blocking the airway.
• Loosen all tight clothing by unfastening top shirt buttons, belts, and skirt or pant buttons. Remove any eyeglasses or tight neck chains. Do not worry about contact lenses. The eye can easily be scratched by trying to remove the small lens during a tonic-clonic seizure.
• Do not hold the person down; you may cause a bone dislocation or get injured yourself.
• Do not put anything in the person's mouth. The tongue cannot be swallowed during a seizure. The muscles for chewing are very strong, so a finger can be bitten, or, an object can be bitten off and the person can choke on the fragment remaining in the mouth.
• After the seizure is over, do not try to restrain the person. He or she may be confused, and restraint may provoke agitation and a violent reaction. Try to keep the person in a safe environment. Walking around is permissible, except near a street, stairs, or other potentially dangerous place.
• Do not give pills, beverages, or food until the person is fully alert.
• Stay with the person until he or she is fully alert and oriented. Be careful. The person may claim to be fine but still be quite confused. Ask a series of questions that require more than a yes or no answer. For example, ask "What is your address?" and "What is the date?"
• If this is the person's first tonic-clonic seizure or if the seizure lasts longer than 5 minutes, call an ambulance.
• During and after the seizure, keep onlookers away. One or two people can be responsible for first aid. Additional people often add confusion. Further, it can be embarrassing for the person to awaken to a crowd of people.
• After the seizure is over and calm has been restored, the eyewitness should tell the person who had the seizure what actually happened and the duration of the seizure, and, most importantly, should provide reassurance and support.

After the seizure, the person may complain of headache, mouth discomfort from tongue- or cheek-biting, or back pain related to the muscular contractions or a fall. Acetaminophen (Tylenol) or ibuprofen (Advil) is helpful for minor pains. If back pain is severe, the person should be seen by a doctor because there is the possibility of a fracture, which is usually treated conservatively with rest. Fever may follow a seizure, usually because of the muscle activity and the effects of the seizure. If the fever is unusually high (over 102°F), lasts more than 6 hours, or develops more than 3 hours after a seizure, it is wise to consult with a doctor. Sometimes secretions pass down the respiratory tract during the seizure and cause pneumonia.

If a person has a history of tonic-clonic seizures that last more than 5 minutes, it is often wise to have drugs on hand that can be given if another such prolonged seizure occurs. This is especially important for patients who live far from a hospital or who are travelling to remote areas (going camping, for instance). Appropriate drugs for this purpose include diazepam given by rectum (Diastat), for all age groups, or lorazepam given sublingually (under the tongue), for an older child or a teenager. The doses of these drugs should be carefully reviewed with the physician, including when a second dose of rectal diazepam or sublingual lorazepam may be given if seizure activity persists.

Topic Editor: Steven C. Schachter, M.D.
Last Reviewed:12/15/06

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