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Seizures
and Epilepsy - Frequently Asked Questions
by James A. Whitlock,
Jr., MD
Staff Neurologist
Northeast Rehabilitation Hospital, Salem, NH. USA
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.
Contents
First, what
NOT to do
What TO do
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?
-
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.
-
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.
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.
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?
-
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;
-
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" (as
illustrated below).
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 as illustrated 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" (illustrated here).
-
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.
[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.
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].
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?
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.
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.
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.
For lengthier or more reflective
comments, feel free to write me at:
Northeast Rehabilitation Hospital
70 Butler Street
Salem, NH 03079
Acknowledgments:
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
Last Updated:
06/21/06 |
©2006 Northeast Rehabilitation Health Network
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