Contents
What
observations about a seizure might be important to a physician?Should
an extra dose of anticonvulsant be given after a seizure?Is
there anything other than meds that can help prevent/control seizures?
What is a seizure? If
someone has a seizure, does that mean they suffer from epilepsy?
A seizure is a change in behavioral
state which results from abnormal electrical activity in the brain. Given the
right set of circumstances (e.g. – blow to the head, intoxication, high fever)
anyone can experience a seizure. The occurrence of a seizure in the presence of
some acute precipitating physiological disturbance does not mean that it will
ever happen after the precipitating cause has resolved. When seizures recur
without any obvious precipitant or cause, then a person may be considered to
have epilepsy.
What happens during a seizure?
"Grand
Mal" – Primary Generalized, Tonic-Clonic Seizures
The true generalized seizure is
characterized by sudden loss of consciousness, usually without warning. At onset
there is usually a general stiffening of the body, often with forceful
expiration of air (and a peculiar sound as this air passes through the throat).
If the person having the seizure is standing when this happens, there can be a
hard fall to ground or floor. This "tonic" phase of the seizure is
generally very brief but is responsible for a number of things which often
frighten witnesses. Because virtually all skeletal muscles in the body are
forcefully contracting at the same time, there may be biting of the tongue,
passage of urine, (rarely) defecation or vomiting, and sometimes a change in
color to a purplish-blue (due to muscles of respiration being stuck in the
tightened state). This phase generally lasts about 30 seconds.
Immediately following the ‘tonic’
phase of a seizure, convulsing begins as forceful, rhythmic jerking of arms,
legs, head and neck. This activity is variable in both its forcefulness and its
duration, but it can last a couple of minutes, building up in intensity and then
fading out while the frequency of shaking remains relatively constant.
Skin/lip/nail bed color generally returns to normal during this period.
After the convulsing ceases, there is
usually a state of deep sleepiness. During this period, all the muscles that
were convulsing are deeply relaxed. If a person in this state is in a position
which makes it hard for them to breathe, they may NOT change their own position
(see following section). The folklore about people with seizures
"swallowing their tongue" actually relates to the possible airway
obstruction which can occur in a person who is on their back with their head
flexed forward during the very sleepy period after a major convulsion.
As the sleepiness lightens, a person
recovering from a seizure may initially be confused or even hard to engage in
conversation beyond a few words. The confusion more often than not passes over
minutes, but the desire for a retreat to bed to sleep for a while sometimes
lasts for quite a while.
If a generalized convulsion is
prolonged (5 minutes or more) or if it is followed by a second seizure before
complete recovery (person is awake and interactive), it is time to seek medical
assistance.
"Temporal Lobe
Epilepsy" – Complex Partial Seizures (often erroneously labeled ‘petit
mal’)
The second most common form of seizure
in adults is "partial" (i.e.-the electrical ‘storm’ involves some but
not all of the brain) "complex" (i.e.- disturbance of consciousness).
Usually the area of brain involved in the seizure activity is the temporal lobe.
But other parts of the brain can give rise to seizures which fall under this
heading. What most of these seizures have in common is:
Some form of warning or
"aura" with an awareness that something is about to happen. This
may take the form of a mental picture, a noxious odor, an unusual sensation
in the stomach, the perception of a voice or music, even a particular
recollection;Loss of awareness without
collapse/unconsciousness (as if ‘auto-pilot’ takes over);Duration of minutes during which
there may be automatisms — repetitive, non-purposeful acts — (eg.- lip
smacking, swallowing, picking at things, garbled or semi-random speech,
aimless walking or manipulation of objects);A period of confusion lasting
minutes after the episode, possibly with sleepiness (but not the profound
somnolence that generally follows a major convulsion). The person in this
state may walk around, as if with purpose. Rarely, aggression may be
manifest during this phase – especially if someone is attempting to
passively restrain/direct movement. This aggression, when manifest, is not
well-focused, not ‘thought-out’ and can often be avoided by leaving the
person alone for a few minutes.
There is actually quite a bit of
variety in the behavior individuals with this type of seizure exhibit. But once
a seizure of this type has expressed itself in an individual, any subsequent
episode generally has the same aura and outward behavioral appearance as the
first one.
There is total amnesia for the period
of the seizure and variable amnesia for events just preceding and following it.
Sometimes, in some persons, this type of seizure precedes a generalized
convulsion (see above) as the electrical signal spreads out from one part of the
brain to the entire brain.
"Focal Fits"
– Simple Partial Seizures
Seizures which involve only part of
the brain ("partial") without alteration of awareness
("simple") can occur in persons who have had injury to the brain (as
from trauma, stroke, hemorrhage, malformation, tumor). Most commonly, they
involve rhythmic (2-3 cycles/second) twitching of face, hand/arm, and/or leg on
the side of the body opposite to the side of brain from which the seizure
emanates. Generally, this type of seizure lasts minutes. In some individuals, it
forms the prelude to a generalized convulsion. Occasionally, it can go on for a
very long time (hours-days). The longer it lasts, the greater the associated
fatigue. Extremely prolonged versions of this seizure type can interfere with
sleep, cause muscle pain and lead to exhaustion.
The true "petit mal" seizure
type (also known as "Absence Attacks" or technically, "Primary
Generalized Seizures – Absence Type") is observed almost exclusively in
children. It is mentioned in this section only to assist in the campaign for
accurate terminology.
Absence seizures are characterized by
abrupt and brief interruption of consciousness without convulsion. During the
typical, seconds-long episode there is "loss of contact",
"spacing out" rarely with chewing, swallowing, or blinking
automatisms. Sometimes an individual continues doing whatever they were doing at
seizure onset, though in an automatic way. During the episode, interaction is
not possible. These episodes can be very brief, subtle and easily missed by a
nearby observer. Normally, whatever activity a child was engaged in before the
seizure is continued following it. Sometimes children with these seizure types
are misdiagnosed with learning or behavioral problems.
There are a host of seizure types
which are seen only in children or infants.
If I see someone having a convulsion, what
can I do?
DO NOT TRY TO PUT
ANYTHING IN THE PERSONS MOUTH;There is no place for the
"tongue blade" at the bedside or in the home. In fact, it is
dangerous. Many sticks, teeth, and other things have been broken by
persons attempting to prevent "swallowing of the tongue". The
same applies to fingers – never place anything in the mouth of a person
who is actively seizing/convulsing.It is sometimes appropriate to
place an oral airway after the seizure has ended, but only if you’ve
been trained in its use (and there happens to be one present). There is
another way to deal with the airway during the profound sleepiness which
sometimes follows a seizure — (read on).
DO NOT TRY TO
RESTRAIN THE CONVULSING LIMBS;Soften the surface, remove
obstacles/furnishings, get the person to a safe spot, cushion head with
your hands, YES. Restrain, NO.
IF A PERSON KNOWN
TO HAVE ‘CONVULSIVE’ EPILEPSY SHOWS A COLOR CHANGE TOWARD BLUE IN FACE,
LIPS, NAIL-BEDS AT THE ONSET OF A SEIZURE- COUNT TO 60;The cyanosis (bluing of lips,
nails, skin) that may accompany what in essence is a brief
"respiratory arrest" at the beginning of a convulsion is
caused by contracted and ‘stuck’ respiratory muscles. It is not
something that can be altered by any bystander/caregiver. It should pass
relatively quickly, with improvement in color as the convulsion
proceeds.If the above state lasts
beyond a minute, OR if it is followed by relaxation (instead of
convulsive movements) with persistent bluish color, it would probably be
wise to assume that this IS a respiratory arrest and NOT a seizure. [In
which case the proper response would be Basic Life Support].
DO NOT ATTEMPT TO
GIVE THE PERSON MEDICATION/FLUIDS WHILE THEY ARE NON-INTERACTIVE;The person should be talking
before any attempt is made to give anything by mouth.
Now, what TO do.
(Sometimes the most important things are the simplest) –
Especially if this is the first
seizure you’ve ever witnessed, or if you don’t know anything about the
person’s medical history, feel for the carotid pulse. Feeling this should
provide the necessary reassurance that the individual is not experiencing a
cardiac arrest. Hopefully, you can relax enough to remember the following
tips –Create the safest possible
environment for the seizure. Position away from objects which threaten
injury. Provide a soft surface, if possible. Cushion head with hands to
prevent banging of head against the ground/floor.As the seizure ends and a state of
deep relaxation ensues, place the person in the "recovery
position" (as illustrated below).
Never should the individual be left flat on their back – that position
invites airway obstruction (by a relaxed/swollen tongue dropping to the back
of the throat, blood from a bitten tongue, or vomitus). If, after
positioning the person as illustrated there is any sign of ineffective
breathing (loud snoring type sound, little/no air moving to/from
mouth/nose), ensure that there is nothing in the mouth by sweeping your
finger through, removing any debris as you do so [NOTE WELL- The seizure has
stopped at this point and the person looks as if deeply asleep]. If there
are dentures, this is the time to remove them. If after doing the foregoing
there is still a loud snoring sound, try extending the neck a bit more.
Other options to help open the airway include use of an oral airway or a
performance of a "jaw thrust maneuver" (illustrated here).
Recovery should proceed over
minutes, though significant fatigue is likely. If there has not been any
injury (eg.- no significant cuts to skin or tongue or concern regarding
injurious effects of a fall to ground/floor), the person should be allowed
to fulfill their desire to rest.Seek medical/hospital treatment if
their is any concern about significant injury or if this is the individual’s
first seizure.
A couple of unusual
situations-
[Author’s note: I doubt that it would
be possible to address every contingency pertaining to responses to seizure in
any document – even in the ultimate hyperlinked Web-work. Hopefully, the most
common scenarios will ultimately be well addressed in these pages.]
There are a couple of unusual
circumstances that are worth noting, especially because awareness can have a
major impact upon outcome in particularly dangerous situations.
Seizure in water (e.g. –
swimming). No one should swim alone. Persons known to have epilepsy of any
type should not swim without their escort realizing that a seizure in water
can be a particularly dangerous thing. During the forced expulsion of air at
seizure onset, a seizing person would tend to sink quite rapidly. Then, with
onset of the convulsive activity, water would tend to be drawn into the
lungs. In non-convulsive seizure disorders, the impairment of awareness or
movement control could pose some difficulty to a rescuer, but should not be
dangerous as long as the head is kept above the water. Bottom-line? Consider
the depth of water used during recreation as well as use of device which add
some buoyancy.Concern about possible neck injury
in fall during a seizure. Fortunately, it seems to be remarkably rare for
serious injuries to accompany seizures. Still, occasionally the fall at
seizure onset is a hard drop to a hard surface. Especially in medical
settings, such an occurrence tends to reflexively result in taking extra
precautions with respect to possible neck injury. This means applying
traction to the head in such a way as to minimize flexion/extension
movements, especially after the convulsion ends. There is still a need to
move the person into the recovery position, the difference being that
someone has to continuously hold the head in such a way as to keep the spine
straight. This can pose a bit of difficulty for one attendant if the person
who had the seizure is having difficulty breathing. This situation calls for
a "jaw thrust", with the caveat that the neck should not be
extended.Seizures which are prolonged or
which occur one after another… are a special circumstance in that they may
hurt the brain. Emergency medical attention should be sought immediately.
What observations
about a seizure (or what I think was a seizure) might be important to my
physician?
The observations of a witness are
generally key to diagnosing the various forms of seizure and in distinguishing
seizures from episodes that can be confused with them (such as faints, various
forms of tremor, and a host of unusual causes of episodic behavioral phenomena).
While patients can often provide key information (or all the information
necessary when there is no interruption of consciousness), a witness/observer is
the only one who can provide the information which leads to an accurate
diagnosis. Specific observations have particular relevance depending upon the
whether this is a person’s first seizure, a recurrent seizure or an episode
differing from past seizures.
In general, it might be good to write
down your observations soon after the episode while memory is fresh, using the
following as a guide. [Some questions would best be directed to the person who
had the episode, others to a witness].
What was the person doing
immediately before the episode?Has there been any traumatic loss
of consciousness in the recent (or remote) past? [Be able to provide
details]. Has there been any recent illness (fever, "flu")?Did the person seem to have a
feeling that something was about to happen before the episode? Was it even
more specific than a ‘feeling’?As the seizure began, what did you
see first? Was there any color change in skin, lips or nail-beds? Were there
movements of eyes to one side? If so, which side? Did one side of the face
twitch before the other? Did one limb start jerking before another? [In
general, if any movements or postures were seen more on one side than
another, it can be helpful to know which side did what.]In non-convulsive episodes, a
description of exactly what the person did/said during and shortly after the
episode would be helpful. Note the duration of the spell; between onset and
resolution of any confusional period which follows.Was there passage of urine? of
stool? Any vomiting?Was there any bleeding in the
mouth?How long did the jerking part of
the episode last?After the episode, what did the
person do?
Did this seizure look the same as
prior ones?Was it longer or shorter than
average?Have there been any recent
medication changes or missed doses of medication?Has there been any recent change
in sleep habit (eg.- up all night preceding the day of the seizure)?How much (if any) recent alcohol,
caffeine, marijuana, or cocaine has been used? When was it last used in
relation to the time the episode/seizure happened?Are there any new medications
(prescription or non-prescription) being taken? Any herbal remedies?Have there been any unusually
stressful events in life recently?Has there been any major change in
weight since the last seizure? [Occasionally, a significant weight change
may be associated with a change in blood anticonvulsant level in an
individual who had long shown a stable blood level].
Recurrent Seizure,
but Different from Previous Seizures
In addition to answers to questions,
from the above section ("Recurrent Seizure") please consider the
following:
Exactly how was the episode
different from previous ones? Was there a different ‘warning’ or
"aura"? Did the spell involve a different part or side of the
body? Did it start differently?Has there been any recent illness,
new symptom of a possible illness? Any recent injury – especially blow to
the head?
"Should an extra
dose of anticonvulsant be given as soon as possible after a seizure?"
In someone who is taking
anticonvulsant/anti-epileptic medication, a "breakthrough" seizure may
be a sign of a blood anticonvulsant level which has fallen too low. But
occasionally (uncommonly) a seizure can be a manifestation of toxicity from too
much anticonvulsant in the system. Thus, unless there have been prior directions
from a physician covering this contingency, or it is known that a scheduled dose
of medication was missed, it is probably most wise to seek direction from your
physician/neurologist before giving any extra medication.
It is easier for a physician to
provide well-grounded advice regarding starting an anticonvulsant when a seizure
disorder has developed or when a person is at unusually high risk for having
seizures. Providing advice regarding when to discontinue medication in the
absence of seizures is much more difficult. There needs to be a reasoned
weighing of ongoing risk of seizure recurrence against factors such as
medication side-effect(s), cost of medications, potential drug interactions,
willingness to defer driving during and for a while after the withdrawal of
anticonvulsant. These are matters best discussed with your
physician/neurologist.
"Is there
anything other than medication that can be done to help prevent seizures?"
Seizure activity can be evoked from
any brain given the right combination of circumstances. The concept of a
"seizure threshold" is based upon the fact that with enough
physiological or pharmacologic ‘stress’, seizures can happen in any mammal
(including humans). Individuals differ in what constitutes "enough" of
a stress. Some of the factors which influence seizure threshold include genetics
(family history), brain trauma (especially "open" or penetrating
wounds to brain), a number of medications and drugs (including things not often
thought of as "drugs"), body temperature, sleep deprivation and a host
of metabolic variables (for example: blood sugar, blood oxygen level, blood
minerals, hormones).
There are a number of
frequently-overlooked habits which can have a bearing upon seizure risk.
Caffeine (found in coffee, tea,
over-the-counter ‘stay-awake’ pills and many carbonated beverages) lowers
seizure threshold. This doesn’t mean that all persons with or at risk for
seizures should abstain completely from anything with caffeine in it. It
just means that moderation is probably wise here, especially if prevention
of recurrent seizure is proving difficult.Alcohol makes it easier to have a
seizure. It does so both as its level rises in the blood stream and as it
later falls. It also tends to interact with just about every drug used to
treat or prevent epilepsy. Because of its complex effects upon metabolism,
body water and mineral balance, sugar metabolism and even sleep, alcohol use
should probably be avoided in anyone who has had or is at special risk of
seizure.Sleep-deprivation (as in changing
from day-shift to night-shift work, or staying up all night to work on a
term paper, etc.) probably does much to lower seizure threshold.Combinations of the above are,
more likely than not, additive in there effects.
"What are some
good sources of additional information regarding seizures and epilepsy?"
For lengthier or more reflective
comments, feel free to write me at:
Northeast Rehabilitation Hospital
70 Butler Street
Salem, NH 03079
Acknowledgments:
Thanks to Carl Billian, MD, Greg Lipshutz,
MD and J. Prochilo for their critical reviews of this work and to N. Druke for
kindly helping with illustrations.
Copyright © James Whitlock, MD