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generalized tonic-clonic (grand-mal) seizure (GTCS, PGTCS, PGTC)

for Etiology:, Epidemiology: & Pathology: (see seizure) Clinical manifestations: 1) aura (controversial), none according ref [6] a) minutes to hours b) emotional changes c) epigastric fullness d) hallucinations 2) sudden loss of consciousness 3) violent generalized muscle contraction, tonic (tonic seizure) or jerking (clonic seizure) a) occurs early b) generally lasts < 30 seconds 4) rhythmic clonic jerking movements a) occurs late b) lightening like jerks of the arms [6] c) generally lasts 30-60 seconds 5) eyes remain open [6] 6) cyanosis due to respiratory arrest 7) biting of tongue on side of tongue - biting tip of tongue is malingering 8) autonomic changes a) incontinence (not common) b) tachycardia c) increased blood pressure d) mydriasis e) superior ocular deviation f) apnea 9) duration generally 1-2 minutes; 2-5 minutes [6] 10) post-ictal state a) 5-15 minutes b) confusion, headache, fatigue, amnesia, weakness c) prolongation of post-ictal state may occur in elderly patients [5] 11) Todd's paralysis Laboratory: (see seizure) Radiology: (see seizure) Management: 1) immediate management - diazepam buccal film interictal, ictal/peri-ictal poorly controlled tonic-clonic seizures or focal seizures with impaired awareness [8] 2) agents of choice a) valproic acid* (drug of choice, least expensive) [6] b) lamotrigine (second choice) [6] 3) alternative agents a) levetiracetam b) topiramate* c) zonisamide 4) adjunctive agents for refractory seizures [3,4] 1) topiramate* 2) lamotrigine 5) women of child-bearing age a) lamotrigine [6] b) levetiracetam c) avoid valproate & topiramate* 6) elderly a) lamotrigine [6] b) levetiracetam 7) liver failure a) levetiracetam b) avoid valproate 8) renal failure a) lamotrigine [6] b) levetiracetam 9) patients with concurrent mood disorder a) lamotrigine [6] b) valproic acid c) avoid levetiracetam 10) some narrow spectrum anticonvulsants can exacerbate generalized seizures including: - carbamazepine, gabapentin, oxcarbazepine, phenobarbital, phenytoin, pregabalin [6] 11) Embrace smart watch for seizure tracking & epilepsy management uses advanced machine learning to identify convulsive seizures & sends an alert via text & phone message to caregivers [7] * avoid valproate & topiramate in women of child-bearing age [6]

Related

Todd's paralysis

General

primary generalized seizure

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1034-35
  2. Alan Gelb, UCSF, Department of Emergency Services, San Francisco General Hospital, 1998
  3. Biton V et al, Double-bind, placebo-controlled study of lamotrigine in primary generalized tonic-clonic seizures. Neurololgy 2005, 65:1737 PMID: 16344515
  4. French JA et al, Efficacy and tolerability of the new antiepileptics drugs 1: Treatment of new onset epilepsy: Report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004 62:1250 - French JA et al, Efficacy and tolerability of the new antiepileptics drugs II: Treatment of refractory epilepsy: Report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004 62:1250
  5. Sheth RD et al, Protracted ictal confusion in elderly patients. Arch Neurol 2006; 63:529 PMID: 16606764
  6. Medical Knowledge Self Assessment Program (MKSAP) 14, 17, 18. American College of Physicians, Philadelphia 2006, 2015, 2018
  7. Brooks M. FDA Clears First Smart Watch to Detect Seizures, Manage Epilepsy. Medscape - Feb 06, 2018. https://www.medscape.com/viewarticle/892329
  8. George J Diazepam Film Shows Promise for Poor Seizure Control. Buccal film placed successfully during seizure clusters. MedPage Today. Dec 06, 2018 - Jung C, et al. The usability of diazepam buccal soluble film as an oral treatment in adult patients with epilepsy. AmericanEpilepsy Society (AES) 2018; Abstract 3.468. - Rogawski M, et al. Pharmacokinetics of diazepam buccal soluble film in adult patients with epilepsy: comparison of bioavailability with peri-ictal and interictal administration. AmericanEpilepsy Society (AES) 2018; Abstract 2.453.