Seizure first aid

It’s helpful to know what to do if you witness someone having a seizure. If you’re at risk of having seizures in the future, pass this information along to family, friends and co-workers so that they know what to do if you have a seizure.

To help someone during a seizure:

• Carefully roll the person onto one side
• Place something soft under his or her head
• Loosen tight neckwear
• Remove eyeglasses
• Avoid putting your fingers or other objects in the person’s mouth
• Don’t try to restrain someone having a seizure
• Clear away dangerous objects, if the person is moving
• Stay with the person until medical personnel arrive
• Observe the person closely so that you can provide details on what happened
• Time the seizure
• Check for a medical alert bracelet or ID
• Stay calm

When to see a doctor

Seek immediate medical help if any of the following occurs:

• The seizure lasts more than five minutes.
• Breathing or consciousness doesn’t return after the seizure stops.
• A second seizure follows immediately.
• You have a high fever.
• You’re experiencing heat exhaustion.
• You’re pregnant.
• You have diabetes.
• You’ve injured yourself during the seizure.

If you experience a seizure for the first time, seek medical advice.

Lifestyle and home remedies

Here are some steps you can take to help with seizure control:

• Take medication correctly. Don’t adjust the dosage before talking to your doctor. If you feel your medication should be changed, discuss it with your doctor.
• Get enough sleep. Lack of sleep can trigger seizures. Be sure to get adequate rest every night.
• Wear a medical alert bracelet. This will help emergency personnel know how to treat you correctly if you have another seizure.

Personal safety

Seizures don’t usually result in serious injury, but if you have recurrent seizures, injury is a possibility. These steps can help you avoid injury during a seizure:

• Take care near water. Don’t swim alone or relax in a boat without someone nearby.
• Wear a helmet for protection during activities such as bike riding or sports participation.
• Take showers instead of baths, unless someone is near you.
• Modify your furnishings. Pad sharp corners, buy furniture with rounded edges and choose chairs that have arms to keep you from falling off the chair.
• Consider carpet with thick padding to protect you if you do fall.
• Display seizure first-aid tips in a place where people can easily see them. Include any important phone numbers there, too.

Diet therapy

Following a diet that’s high in fat and low in carbohydrates, known as a ketogenic diet or keto diet, can improve seizure control. Variations on a high-fat, low-carbohydrate diet, such as the low glycemic index and modified Atkins diets, though less effective, aren’t as restrictive as the ketogenic diet and may provide benefit.

Grand mal seizure complications

Having a seizure at certain times can lead to circumstances that are dangerous for you or others. You might be at risk of:

• Falling. If you fall during a seizure, you can injure your head or break a bone.
• Drowning. If you have a seizure while swimming or bathing, you’re at risk of accidental drowning.
• Car accidents. A seizure that causes either loss of awareness or control can be dangerous if you’re driving a car or operating other equipment.
• Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. If you have epilepsy and plan to become pregnant, work with your doctor so that he or she can adjust your medications and monitor your pregnancy, as needed.
• Emotional health issues. People with seizures are more likely to have psychological problems, such as depression and anxiety. Problems may be a result of difficulties dealing with the condition itself as well as medication side effects.

Can you die from a grand mal seizure

You can’t die from a grand mal seizure, but death is probably depending on what you were doing at the time your grand mal seizure occurs. For example, if you were scuba diving alone and have a grand mal seizure – you’re at risk of accidental drowning or you are driving a car or operating heavy equipment and have a grand mal seizure.

Sudden unexpected death in epilepsy (SUDEP)

Epilepsy is common, affecting one in every 200 people. People with epilepsy have a significantly higher mortality than people who do not have epilepsy: the rate of death from any cause in patients with epilepsy is 2-3 times higher than that of the general population.

This increased mortality is due to a variety of causes, such as accidents (trauma, drowning) during seizures, suffocation, suicide, and death due to other conditions (such as brain tumors) that lead to seizures.

The most common single epilepsy related cause of death is Sudden Unexpected Death in Epilepsy (SUDEP). In people with Sudden Unexpected Death in Epilepsy (SUDEP), no cause for death is found at post mortem. The risk of sudden death in people with epilepsy (SUDEP) is estimated to be 24 times greater than for those without epilepsy.

Sudden Unexpected Death in Epilepsy (SUDEP) is diagnosed when there is an unexpected non traumatic (such as head injury) and non drowning death in an individual with epilepsy. It may be witnessed or un-witnessed, and may occur following a seizure or not. It must not occur due to status epilepticus (prolonged seizure that does not respond to medication), inhaling (aspiration) of stomach contents, or any kind of poisoning. To be classified as Sudden Unexpected Death in Epilepsy (SUDEP), there must be no evidence of a cause of death due to drugs or other diseases at post mortem examination. The person does not have to have been known to have a seizure just before their death (although this is often the case), but they must have been diagnosed with epilepsy in the past.

It is important to note that ‘sudden death’ is not the same thing as ‘instantaneous death’. Sudden death is defined as death occurring within an hour of starting to become unwell.

Sudden unexpected death in epilepsy (SUDEP) is the single most important cause of death in people with epilepsy.

The reported incidence of sudden death in epilepsy varies between studies. When studies relate to higher risk groups, SUDEP is found to be a more frequent cause of death than in lower risk groups. In lower risk groups, such as children with epilepsy, the general population, epilepsy registers and autopsy series studies, SUDEP explained from 0-14% of deaths. In contrast, SUDEP explained 29-75% of deaths within studies where subjects were enrolled in drug trials, epilepsy surgery or surgical candidates, epilepsy clinics and registers of patients with refractory epilepsy.

The frequency of SUDEP in community based populations with epilepsy is estimated as between 1:500 and 1:1000 patient years. That is, if 1000 people with epilepsy were monitored for one year, one of those would die of SUDEP. The highest rates of SUDEP (2.2-10 deaths per 1000 patient years) have been found in candidates for epilepsy surgery, those with severe refractory epilepsy, and those who require input from specialist epilepsy referral centres. Intermediate rates (3.4-3.6 deaths per 1000 patient years) have been found in studies including patients with intellectual impairment. Lowest rates (0.35-2.5 deaths per 1000 patient years) have occurred in studies involving children.Studies of epilepsy in the general population found rates of SUDEP to be 0-1.35 deaths per 1000 patient years studied. For those with severe refractory epilepsy, the risk of SUDEP is about 0.5-1% per year.

Risk Factors for Sudden Unexpected Death in Epilepsy (SUDEP)

Many studies have been performed in an attempt to identify risk factors for SUDEP. Though none have been clearly confirmed, some possible risk factors are summarized below:

• Patient related – young adulthood, male gender, alcohol abuse, being in bed
• Seizure related- more frequent seizures, early age at onset of seizures, long duration of epilepsy, grand mal seizures (tonic- clonic seizure type), seizure within previous year, intractable epilepsy.
• Treatment related- taking multiple anti epileptic medications, poor adherence with antiepileptic drugs, surgery, frequently changing the types or dose of medication taken.

Though individual cases of SUDEP are often reported in medical literature, it has proven difficult to study SUDEP in depth. This is because SUDEP is so rare in the general population. Studies into SUDEP have therefore only been on small groups of patients. However, some useful information has been gathered, both from these studies of small groups of patients, and from animal studies.

The majority of people with newly diagnosed epilepsy will not go on to have seizures in the long term, and within this group SUDEP is an extremely rare occurrence. Studies have therefore tended to focus on individuals with more severe forms of epilepsy, who generally have greater representation within specialist clinics, hospital inpatient settings and residential care. The risk of SUDEP is known to be elevated within this population.

In most studies, the age of death due to SUDEP has been between 25-40 years. However, diagnosing SUDEP in older populations can be difficult as other medical conditions are more likely to be present at autopsy. Death may be mistakenly attributed to these other conditions (such as vascular disease), as by definition SUDEP may only be diagnosed if no other cause of death is found.

The frequency of SUDEP in patients with epilepsy is not always related to the type of, or severity, of seizures experienced. Both major and minor seizures have led to SUDEP. This is because the apparent severity of the convulsions on the outside does not necessarily reflect what is happening in the brain – more severe disturbances in brain activity do not always produce larger seizures. Nevertheless, most cases of SUDEP are said to be associated with seizures of the grand mal (generalised tonic-clonic) type, more severe epilepsy, more frequent seizures, and individuals requiring many antiepileptic drugs.

Most cases of SUDEP occur when the person is in bed. SUDEP may therefore be related to sleep. Whether this is due to a difference in the physiology between nocturnal and daytime seizures, or simply due to lack of supervision and help available at the time is unknown.

Sudden Unexpected Death in Epilepsy (SUDEP) diagnosis

SUDEP is diagnosed when an individual with epilepsy dies suddenly, and no cause (such as drowning, trauma, or choking) can be found during post mortem examination. Although a difficult idea for many families to cope with, medical examination of the body of a person who dies in these circumstances is important to rule out other causes of death which may mimic SUDEP, such as a drug overdose or brain hemorrhage. This information is important so that more can be learned about causes of death in epilepsy, including SUDEP, with the hope of preventing deaths in the future.

Sudden Unexpected Death in Epilepsy (SUDEP) treatment

Unfortunately, scientists do not yet know exactly how to prevent or treat SUDEP. Strategies are suggested by experts in the area, who base their suggestions on identifying and minimizing an individual’s possible risk factors for SUDEP. There is not yet a high level of evidence that proves that these strategies work in preventing SUDEP.

It is likely that the risk of SUDEP can be reduced by making sure that seizure control in all patients with epilepsy is as good as possible, though optimization of medical and surgical management. This remains the most important treatment goal in patients with epilepsy. Aggressive treatment of refractory epilepsy (characterized by uncontrolled seizures), with specialist epilepsy center input and consideration of surgery or vagal nerve stimulation is warranted.

Supervision at night, either with a ‘supervisor’ sharing the same room, regular checks throughout the night, or use of a monitoring device has been associated with a decreased risk of SUDEP.

There is some debate as to the best approach in discussing SUDEP with individuals with epilepsy and their families. Given the rare nature of the condition, some clinicians feel outlining the risk of SUDEP will create needless worry for individuals with epilepsy and their relatives. Increasingly however, the importance of identification of high risk individuals, with subsequent education and use of prevention strategies is being promoted clinically and within the literature. Other strategies that have been suggested are identification of seizure precipitants and promoting compliance with treatment.

Grand mal seizure causes

A grand mal seizure (generalized tonic-clonic seizure) is caused by abnormal electrical activity throughout the brain. The brain’s nerve cells normally communicate with each other by sending electrical and chemical signals across the synapses that connect the cells. In people who have seizures, the brain’s usual electrical activity is altered and many nerve cells fire at the same time. Exactly what causes the changes to occur often remains unknown.

Grand mal seizures (generalized tonic-clonic seizures) may occur in people of any age. Grand mal seizure can occur once (single episode). Usually, a grand mal seizure is caused by epilepsy (a chronic seizure condition). But sometimes, grand mal seizures can be triggered by other health problems, such as extremely low blood sugar, a high fever or a stroke. Some seizures are due to psychological problems (psychogenic).

However, grand mal seizures are sometimes caused by underlying health problems, such as:

Injury or infection

• Traumatic head injuries
• Infections, such as encephalitis or meningitis, or a history of such infections
• Injury due to a previous lack of oxygen
• Stroke

Congenital or developmental abnormalities

• Blood vessel malformations in the brain
• Genetic syndromes
• Brain tumors

Metabolic disturbances

• Very low blood levels of glucose, sodium, calcium or magnesium

Withdrawal syndromes

• Using or withdrawing from drugs, including alcohol

Risk factors for grand mal seizures

Risk factors for grand mal seizures include:

• A family history of seizure disorders
• Any injury to the brain from trauma, a stroke, previous infection and other causes
• Sleep deprivation
• Medical problems that affect electrolyte balance
• Illicit drug use
• Heavy alcohol use.

Grand mal seizure symptoms

Many people with grand mal seizures (generalized tonic-clonic seizures) have vision, taste, smell, or sensory changes, hallucinations, or dizziness before the seizure. This is called an aura.

The seizures often result in rigid muscles. This is followed by violent muscle contractions and loss of alertness (consciousness). Other symptoms that occur during the seizure may include:

• Biting the cheek or tongue
• Clenched teeth or jaw
• Loss of urine or stool control (incontinence)
• Stopped breathing or difficulty breathing
• Blue skin color

After the grand mal seizure, the person may have:

• Confusion
• Drowsiness or sleepiness that lasts for 1 hour or longer (called the post-ictal state)
• Loss of memory (amnesia) about the seizure episode
• Headache
• Weakness of 1 side of the body for a few minutes to a few hours following seizure (called Todd paralysis)

Grand mal seizure diagnosis

After a seizure, your doctor will thoroughly review your symptoms and medical history. The doctor will perform a physical exam. This will include a detailed check of the brain and nervous system. Your doctor may order several tests to determine the cause of your seizure and evaluate how likely it is that you’ll have another one.

Tests may include:

• An EEG (electroencephalogram) will be done to check the electrical activity in the brain. In this test, doctors attach electrodes to your scalp with a paste-like substance. The electrodes record the electrical activity of your brain, which shows up as wavy lines on an EEG recording. The EEG may reveal a pattern that tells doctors whether a seizure is likely to occur again. EEG testing may also help your doctor exclude other conditions that mimic epilepsy as a reason for your seizure. People with seizures often have abnormal electrical activity seen on this test. In some cases, the test shows the area in the brain where the seizures start. The brain may appear normal after a seizure or between seizures.
• Blood tests. Your doctor may take a blood sample to check for signs of infections, genetic conditions, blood sugar levels or electrolyte imbalances.
• Lumbar puncture. If your doctor suspects an infection as the cause of a seizure, you may need to have a sample of cerebrospinal fluid removed for testing.
• Computerized tomography (CT) scan. A CT scan uses X-rays to obtain cross-sectional images of your brain. CT scans can reveal abnormalities in your brain that might cause a seizure, such as tumors, bleeding and cysts.
• Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create a detailed view of your brain. Your doctor may be able to detect lesions or abnormalities in your brain that could lead to seizures.
• Positron emission tomography (PET). PET scans use a small amount of low-dose radioactive material that’s injected into a vein to help visualize active areas of the brain and detect abnormalities.
• Single-photon emission computerized tomography (SPECT). A SPECT test uses a small amount of low-dose radioactive material that’s injected into a vein to create a detailed, 3-D map of the blood flow activity in your brain that happens during a seizure. Doctors may also conduct a form of a SPECT test called subtraction ictal SPECT coregistered to magnetic resonance imaging (SISCOM), which may provide even more-detailed results.

Figure 3. EEG brain activity