From the Guidelines
The treatment for a patient experiencing a grand mal seizure should prioritize ensuring safety, providing supportive care, and administering benzodiazepines as first-line emergency medications, with additional medications like fosphenytoin, levetiracetam, or valproate for prolonged seizures, as recommended by the most recent guidelines 1.
Initial Management
The initial management of a grand mal seizure involves ensuring the patient's safety, which includes placing them on their side in the recovery position to prevent aspiration, clearing the area of dangerous objects, and never restraining them or putting anything in their mouth. Timing the seizure is crucial; if it lasts more than 5 minutes, emergency medication is needed.
Medications
First-line emergency medications include benzodiazepines such as lorazepam (Ativan) 2-4 mg IV/IM, diazepam (Valium) 5-10 mg IV/rectal, or midazolam (Versed) 5-10 mg IM/intranasal. For prolonged seizures (status epilepticus) lasting over 5 minutes or recurrent seizures without recovery, additional medications like fosphenytoin (20 mg PE/kg IV), valproate (40 mg/kg IV), or levetiracetam (60 mg/kg IV up to 4500 mg) may be needed, as supported by recent clinical policy 1.
Supportive Care
Supportive care includes monitoring vital signs, maintaining airway patency, providing oxygen if needed, and protecting the patient from injury. These interventions are critical because seizures can cause respiratory compromise, injury, and in prolonged cases, neuronal damage from excessive electrical activity in the brain.
Evaluation and Long-term Management
After the acute event, the patient should be evaluated to determine the cause and need for long-term antiepileptic medication. The management guidelines should be based on the most recent and highest quality evidence available, such as the clinical policy approved by the ACEP board of directors in 2024 1, which provides Level A recommendations for the management of adult patients presenting to the emergency department with seizures.
From the FDA Drug Label
INDICATIONS AND USAGE Dilantin is indicated for the control of generalized tonic-clonic (grand mal) and complex partial (psychomotor, temporal lobe) seizures and prevention and treatment of seizures occurring during or following neurosurgery. CLINICAL PHARMACOLOGY Phenytoin is an antiepileptic drug which can be used in the treatment of epilepsy. CLINICAL PHARMACOLOGY In controlled clinical trials, carbamazepine has been shown to be effective in the treatment of psychomotor and grand mal seizures, as well as trigeminal neuralgia.
The treatment for a patient experiencing a grand mal seizure may include the use of antiepileptic drugs such as:
- Phenytoin (PO): indicated for the control of generalized tonic-clonic (grand mal) seizures
- Carbamazepine (PO): shown to be effective in the treatment of grand mal seizures It is essential to follow the recommended dosage and administration guidelines for these medications, and to monitor the patient's response to treatment closely. 2, 2, 3
From the Research
Treatment for Grand Mal Seizure
The treatment for a patient experiencing a grand mal seizure typically involves the use of antiepileptic drugs (AEDs) to control and prevent future seizures.
- Antiepileptic Drugs: Studies have shown that AEDs such as lamotrigine, levetiracetam, and topiramate are effective in treating generalized tonic-clonic seizures, including grand mal seizures 4.
- First-Line Treatment: Sodium valproate is often considered a first-line treatment for generalized onset seizures, including grand mal seizures, due to its efficacy and relatively low risk of side effects 5.
- Alternative Treatments: Other AEDs, such as carbamazepine, phenytoin, and phenobarbitone, may also be used to treat grand mal seizures, although they may have different efficacy and side effect profiles compared to sodium valproate and other first-line treatments 6.
- Status Epilepticus: In cases of status epilepticus, which is a medical emergency characterized by prolonged or repeated seizures, AEDs such as levetiracetam, fosphenytoin, and valproate may be used to rapidly control seizures and improve patient outcomes 7.
- Prophylaxis: The use of AEDs as prophylaxis to prevent early post-traumatic seizures in patients with traumatic brain injury is a topic of ongoing debate, with some studies suggesting a potential benefit and others showing limited evidence of effectiveness 8.