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Tonic-Clonic Seizures: Phases, Symptoms, and Management

Tonic-clonic seizures (formerly "grand mal") are the most recognized seizure type, featuring two distinct phases. They can be focal-onset with bilateral spread or generalized-onset.

Phase 1: Tonic Phase (≈10–20 seconds)

  • Sudden loss of consciousness.
  • Generalized muscle stiffening (tonic contraction) → body arches, limbs extend, jaw clenches (risk of tongue biting).
  • Apnea (breathing stops) → cyanosis.
  • Pupillary dilation, tachycardia, blood pressure rise.
  • May produce loud vocalization (forced air through closed vocal cords).

Phase 2: Clonic Phase (≈30–60 seconds)

  • Rhythmic, symmetric jerking of limbs and face (clonic contractions) – frequency slows progressively.
  • Breathing resumes (may be labored, frothing at mouth).
  • Possible urinary/fecal incontinence.
  • Jerking ceases → transition to postictal state.

Postictal Phase

  • Confusion, drowsiness, headache, myalgia, amnesia for event.
  • Duration: minutes to hours.
  • Todd's paralysis (transient focal weakness) possible if focal onset.

Etiology

  • Epilepsy (genetic, structural, metabolic, immune, infectious, unknown).
  • Acute symptomatic: stroke, TBI, CNS infection, metabolic derangement (hypoglycemia, hyponatremia), alcohol/sedative withdrawal, drugs, eclampsia.

Acute Management

  1. Protect from injury (cushion head, clear area).
  2. Time the seizure.
  3. Position: recovery position (lateral) if possible during/after.
  4. Do NOT restrain, put anything in mouth, give oral meds/fluids.
  5. Call EMS if: >5 min, recurrent without recovery, first seizure, injury, pregnancy, diabetes, water submersion.
  6. Rescue meds (if prescribed): IM midazolam, rectal diazepam, intranasal diazepam/lorazepam.

Long-Term Treatment

  • ASMs (anti-seizure medications): levetiracetam, lamotrigine, valproate, carbamazepine, lacosamide, perampanel, etc. – selected by epilepsy syndrome, comorbidities, side effect profile.
  • Epilepsy surgery evaluation if drug-resistant.
  • Dietary therapy (ketogenic, modified Atkins) for specific syndromes.
  • Neuromodulation (VNS, RNS, DBS).

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