Grand Mal (Tonic-Clonic) Seizure: First Aid, Risks of Leaving Unattended & Complications

Immediate First Aid (Do's & Don'ts)

DO	DON'T
Stay calm; time the seizure	Restrain the person
Clear area of hard/sharp objects	Put anything in mouth (spoon, fingers)
Cushion head (folded jacket)	Give water, food, or meds during seizure
Turn onto side (recovery position) after convulsions stop	Attempt CPR unless no pulse after seizure ends
Loosen tight clothing (collar, tie)	Leave unattended
Call 911 if: first seizure, >5 min, repeated, injury, pregnancy, diabetes, water	Assume it's "over" just because shaking stops

Risks of Leaving Unattended

1. Aspiration

Loss of airway protection → saliva, vomit, or gastric contents enter trachea → aspiration pneumonia, ARDS.

2. Trauma

• Head injury (fall, striking objects) – intracranial hemorrhage, concussion.
• Fractures (vertebral compression, long bones from violent contractions).
• Tongue/lip lacerations (self-inflicted).

3. Prolonged Seizure → Status Epilepticus

• Definition: >5 min continuous seizure OR recurrent seizures without recovery.
• Consequences: Neuronal injury (hippocampus, cortex), systemic acidosis, rhabdomyolysis, hyperthermia, cardiovascular collapse, death.
• Treatment window: Benzodiazepines (IM midazolam, IV lorazepam) within 5 min; second-line (fosphenytoin, valproate, levetiracetam) by 20 min; anesthetic induction (midazolam, propofol, pentobarbital) by 40 min.

4. SUDEP (Sudden Unexpected Death in Epilepsy)

• Incidence: ~1/1,000 patient-years (higher with uncontrolled GTCS).
• Mechanisms: Post-ictal central apnea, cardiac arrhythmia, autonomic storm.
• Risk factors: Nocturnal seizures, prone position, lack of supervision, medication non-adherence.

5. Psychosocial Harm

Loss of dignity, fear, reluctance to seek care, social isolation.

Post-Ictal Care

• Monitor airway, breathing, circulation.
• Reorient gently; person may be confused, fatigued, amnestic (post-ictal state).
• Document: onset time, duration, progression, laterality, incontinence, injuries.
• Ensure follow-up with neurologist / epilepsy specialist.

When to Call Emergency Services (911 in US)

• First known seizure.
• Seizure >5 minutes.
• Second seizure before full recovery.
• Difficulty breathing / cyanosis persists post-ictally.
• Injury (head trauma, fracture).
• Occurs in water.
• Person is pregnant, has diabetes, or known heart disease.
• No known epilepsy history.

Never leave someone having a generalized tonic-clonic seizure alone. Your presence can prevent injury and ensure timely emergency response.