Generalized tonic-clonic seizures (formerly called grand mal seizures) involve paroxysmal, uncontrolled neuronal discharge affecting the entire brain, causing loss of consciousness, tonic stiffening, and clonic jerking.

They may begin with or without an aura and usually last 2–5 minutes, followed by a postictal phase of confusion, fatigue, and muscle soreness. Complications include status epilepticus, respiratory arrest, trauma, Todd’s paralysis, and rarely, cardiac arrest.

Pathophysiology

• Diffuse cerebral hyperactivity extending from an initial focus to the whole brain

• Tonic phase: 10–20 seconds of generalized muscle contraction

• Clonic phase: ≈60 seconds of rhythmic jerking and hyperventilation

• Airway compromise may occur due to secretions, apnea, and tongue biting

• Postictal phase includes confusion, headache, fatigue, amnesia, and muscle soreness

What happens During a Generalized Tonic-Clonic Seizure

History and Physical Examination

History:

• If not witnessed, obtain a description from a companion

• Ask about prodromal symptoms, aura, seizure onset, spread, duration

• Inquire about previous seizures, family history, drug therapy compliance, stress, or sleep deprivation

Physical Examination:

• Check for injury, focal neurologic signs, and LOC changes

• Examine arms, legs, and face (including tongue) for trauma or residual weakness

• Monitor vital signs and neurologic status during postictal recovery

Safety Consideration:

• Ensure a safe environment; never restrain or force objects into the mouth

• Turn the patient to one side to prevent aspiration

• Observe and record seizure activity and intervals

Medical causes

Emergency interventions

• Assess airway, breathing, circulation

• Protect the patient: towel under head, remove sharp objects, loosen clothing

• Turn patient on side to prevent aspiration

• Do not restrain or force objects into mouth

• If seizure >4 minutes or recurrent: suspect status epilepticus

  • Establish airway, IV line, oxygen, cardiac monitoring

  • Administer diazepam or lorazepam IV in 10–20 min intervals

  • Correct hypoglycemia with dextrose + thiamine

• Prepare for intubation, suction, NG tube if needed

• Record observations and intervals carefully

Special considerations

• Monitor for recurring seizures postictally

• Prepare for EEG, CT, MRI

• Offer emotional support to patient and family

Patient counseling

• Teach family how to observe and record seizure activity

• Emphasize medication adherence and follow-up

• Discuss possible adverse effects of drugs

• Advise patient to carry medical identification

Pediatric pointers

• Generalized seizures are common in children; 75–90% of epileptics have first seizure before age 20

• Febrile seizures in ages 3 months–3 years may predispose to later epilepsy

• Other pediatric causes: metabolic disorders, perinatal injury, infections, Reye’s syndrome, Sturge-Weber syndrome, AV malformation, lead poisoning, idiopathic

• Rarely, DPT vaccine pertussis component may trigger seizures

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

3. Lehne RA. Pharmacology for Nursing Care. 7th ed. St. Louis, MO: Saunders Elsevier; 2010.

4. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.

5. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.