What is the treatment for grand mal seizures presenting with head turning and rotated eyes during the tonic phase?

Treatment for Grand Mal Seizures with Head Turning and Rotated Eyes During Tonic Phase

For grand mal seizures presenting with head turning and rotated eyes during the tonic phase, first-line treatment should be a benzodiazepine (such as lorazepam 0.1 mg/kg IV/IO), followed by either fosphenytoin, levetiracetam, or valproate as second-line agents if seizures persist. 1

Initial Management

• Establish airway, breathing, and circulation while providing high-flow oxygen and appropriate airway management 1
• Check blood glucose immediately to rule out hypoglycemia as a cause 1
• Establish vascular or intraosseous access for medication administration 1
• Position the patient on their side in the recovery position to prevent aspiration 1

First-Line Medication

• Administer lorazepam 0.1 mg/kg IV/IO (may repeat once after 10 minutes if seizures continue) 1
• If IV/IO access is unavailable, rectal lorazepam may be more effective than rectal diazepam (RR 3.17) 2
• Monitor for respiratory depression, which occurs less frequently with lorazepam (4%) compared to diazepam (21%) 2

Second-Line Medication (if seizures persist after benzodiazepine)

Any of the following agents can be used with similar efficacy 1:

• Fosphenytoin: 18-20 mg/kg IV/IO over 20 minutes 1
• Levetiracetam: 20-60 mg/kg IV (typically 1000-3000 mg in adults) 1, 3
• Valproate: 20-40 mg/kg IV (typically 30 mg/kg at 5 mg/kg/minute) 1

Treatment Selection Considerations

• Efficacy: All three second-line agents (fosphenytoin, levetiracetam, and valproate) have similar effectiveness in terminating seizures (45-47%) 1
• Safety profile: Valproate has lower incidence of hypotension (1.6%) compared to fosphenytoin (3.2%) 1
• For women of childbearing age: Consider levetiracetam or lamotrigine instead of valproate due to teratogenicity concerns 4
• For patients with cardiac issues: Levetiracetam may be preferred over fosphenytoin due to lower cardiovascular risk 1

For Refractory Status Epilepticus

If seizures continue despite first and second-line treatments:

• Call anesthesia for rapid sequence intubation with thiopental (4 mg/kg IV/IO) 1
• Consider additional options: phenobarbital (15-20 mg/kg IV/IO over 10 minutes) 1
• For highly refractory cases: midazolam infusion, pentobarbital infusion, or propofol infusion 1

Specific Features of Head Turning and Eye Deviation

• Head turning and eye deviation during seizures often indicate the seizure's origin is contralateral to the direction of head/eye movement 1
• These features may suggest focal onset with secondary generalization rather than primary generalized seizures 5
• Document the direction of head turning and eye deviation as this may help localize the seizure focus for long-term management 1

Post-Seizure Management

• Monitor for return to baseline mental status within 5-10 minutes after seizure cessation 1
• Search for and treat underlying causes (infection, metabolic abnormalities, trauma, stroke) 1
• Consider EEG monitoring if mental status does not return to baseline 1
• For first-time seizures, neuroimaging (CT or MRI) should be considered 1

Common Pitfalls to Avoid

• Do not restrain the person having a seizure 1
• Do not put anything in the patient's mouth during a seizure 1
• Do not delay treatment of status epilepticus; mortality increases with duration 1
• Avoid carbamazepine for primary generalized seizures as it may worsen this seizure type 6, 4
• Do not assume all tonic-clonic seizures with head turning are the same - careful observation of the sequence helps determine if they are primary or secondary generalized 5