Tonic-clonic seizures Flashcards
Formerly called / features
grand mal seizure
it is the classic convulsive seizure with muscle jerking.
Typical features of sequence:
AURA – CRY – FALL – FIT (clonic then tonic)
- —Incontinence
- – Confusion
initial rigid tonic phase (up to 60 secs)
convulsion (clonic phase) (seconds to minutes)
mild coma or drowsiness (15 mins to several hrs)
Atypical tonic-clonic seizures
These variants of tonic-clonic seizures
- more common than realised:
stiffen and fall = tonic
floppy and fall = atonic
shaking only = clonic
Diagnosis
Check short-term aggravating factors e.g.
- lack of sleep
- medications
- drugs inc. alcohol
Investigate and treat any cause.
Usual tests—
- EEG
- CT or MRI (preferable) scan
- basic biochemistry and haematology
Treatment
Tonic-clonic (dangerous!)
Give a benzodiazepine followed by an anti-epileptic agent;
- ensure adequate oxygenation:
- attend to airway (e.g. Guedel tube);
- give O2 8 L/min
Midazolam 5–10 mg (child 0.15–0.2 mg/kg up to 10 mg) IV
- or IM over 2–5 min or
- 5–10 mg bucally (between gums and cheek) with syringe
- or intranasally.
- Repeat in 15 mins if necessary or
Diazepam 0.05 mg/kg/min (or 0.2 mg/kg stat) IV
- until the seizures cease or respiratory depression begins
- (beware of respiratory depression and other vital parameters);
- usually give 10–20 mg bolus in adult or
Clonazepam 1–2 mg IV statim
- then 0.5–1 mg/min IV
- until seizures cease or respiratory depression begins or
Followed by (for all of above benzodiazepines) phenytoin 1000 mg IV over 20–30 mins
Other drugs to consider:
- phenobarbitone
- thiopentone
- paraldehyde
- sodium valproate (can use rectally)
Midazolam
is suitable for all types of seizures
can be given:
- (preferentially) intranasally or
- bucally
- rectally by solution, suppository or gel.
In an adult, 10 mg is diluted in 5 mL, of isotonic saline and introduced via the nozzle of the syringe into the rectum.
The dose in children is 0.5 mg/kg.
