What is a grand mal seizure?

Grand Mal Seizure: Definition and Management

A grand mal seizure, now more commonly referred to as a generalized tonic-clonic seizure, is characterized by abnormal excessive neuronal activity affecting both hemispheres of the brain simultaneously, resulting in loss of consciousness, rigid muscle contractions (tonic phase) followed by rhythmic jerking movements (clonic phase), and a postictal period of confusion. 1

Clinical Presentation

• Generalized tonic-clonic seizures involve full-body rhythmic jerking with alterations in consciousness, often accompanied by urinary incontinence 2
• The seizure typically progresses through distinct phases:
  • Tonic phase: rigid muscle contractions throughout the body
  • Clonic phase: rhythmic jerking movements of all extremities
  • Postictal phase: period of confusion, fatigue, and altered mental status lasting several minutes after seizure activity stops 2
• These seizures can be either primary (arising from both hemispheres simultaneously) or secondary (beginning as a focal seizure that spreads to become generalized) 3

Epidemiology and Significance

• Approximately 10% of the population will experience at least one seizure during their lifetime 1
• Generalized tonic-clonic seizures are the most common type of convulsive disorders in children 3
• Primary generalized tonic-clonic seizures are often manifestations of idiopathic epilepsy and may be genetically determined 3
• Secondary generalized seizures frequently indicate central nervous system lesions or symptomatic forms of epilepsy 3

First Aid Management

• For a person experiencing a generalized tonic-clonic seizure, first aid providers should:
  • Activate emergency medical services (EMS) for first-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, or seizures with complications 2
  • Help the person safely to the ground and place them on their side in the recovery position 2
  • Clear the area around the person to prevent injury 2
  • Stay with the person throughout the seizure and recovery period 2
• Do not attempt to restrain the person or place anything in their mouth during the seizure 2

Medical Management

• Initial medical management focuses on:
  • Establishing adequate airway and respiratory support 2
  • Checking blood glucose levels, as hypoglycemia may precipitate seizures 2
  • Administering appropriate anticonvulsant medications if the seizure is prolonged 2
• For prolonged seizures or status epilepticus (seizures lasting >5 minutes), medication options include:
  • Lorazepam (0.1 mg/kg IV/IO) 2
  • Phenytoin (loading dose 18 mg/kg IV/IO over 20 min) 2
  • Phenobarbital (15-20 mg/kg IV/IO over 10 min) 2
• Valproic acid is considered a first-choice medication for primary generalized tonic-clonic seizures in males and menopausal women, while lamotrigine and levetiracetam are viable alternatives for women of childbearing age 4

Complications and Prognosis

• Potential complications include:
  • Respiratory depression, especially with multiple doses of benzodiazepines 2
  • Status epilepticus, a medical emergency with mortality rates of 5-22% 2
  • Raised intracranial pressure, particularly in prolonged seizures 2
• The risk of seizure recurrence varies based on underlying etiology and epilepsy type 3
• Mortality risk is increased in patients with epilepsy, with rare cases of suicide reported in the postictal period 5

When to Seek Emergency Care

• First seizure occurrence
• Seizures lasting longer than 5 minutes
• Multiple seizures without return to baseline mental status between episodes
• Seizures occurring in water
• Seizures with traumatic injuries, breathing difficulties, or choking
• Failure to return to baseline mental status within 5-10 minutes after seizure activity stops 2