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.
Other Seizure Types
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?
First, what NOT to 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".
- 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 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".
- 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.
"I haven't had a seizure in years but I still take medication to prevent seizures. Am I supposed to take this for the rest of my life?"
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?"
- Your friendly neighborhood physician/neurologist.
- The Epilepsy Foundation of America (Telephone: 1-800-332-1000) - a trove of educational resources, including bibliographic lists, videotapes, brochures and pamphlets.
- Engel, J. Seizures and Epilepsy. Philadelphia: FA Davis, 1989.
- Menkes, JH and Sankar, R: Paroxysmal Disorders. In Textbook of Child Neurology, 5th edition. Baltimore: Williams and Wilkins, 1995.
For lengthier or more reflective comments, feel free to write me at:
Northeast Rehabilitation Hospital
70 Butler Street
Salem, NH 03079
Disclaimer: The information herein is presented without warranty regarding its accuracy, completeness, timeliness or correctness for a particular purpose and is not meant to be a substitute for professional medical advice. The reader is advised to always seek the advice of their physician prior to changing any treatment or to receive answers to questions regarding a specific medical condition.
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
From the Northeast Rehabilitation Health Network. Copyright © James Whitlock, MD. Reprinted with permission. All rights reserved. www.northeastrehab.com.
From the Northeast Rehabilitation Health Network. Reprinted with permission. All rights reserved. www.northeastrehab.com.