seizures are defined as a transient occurrence of signs and symptoms due to abnormally excessive or synchronous neuronal activity in the brain they are classified into several types the first thing to consider is where the seizure originated in the brain generalized seizures begin involving both hemispheres of the brain previously they were known as primary generalized seizures on the other hand focal seizures originate from an area on one hemisphere if seizures begin on one hemisphere and then involve both sides they are known as focal to bilateral seizures this was previously called secondary generalized seizures the next factor is whether or not the patient keeps their awareness during the seizure generalized seizures are automatically considered to affect awareness therefore this distinction only applies to focal seizures meaning you either have focal aware previously known as simple partial or focal impaired awareness previously complex partial then we have motor or non-motor seizures motor implies the involvement of movement during the seizure generalized seizures may feature stiffening and jerking while focal seizures can have movements such as twitching jerking and stiffening too but they may also feature automatic movements like licking lips or rubbing hands in focal seizures initially one group of muscles may be affected but this abnormal movement can later spread or move to other muscle groups this occurs due to the abnormal neuronal activity in the brain also moving to a different area this is known as the jacksonian march generalized non-motor seizures are mostly known as absence seizures where primarily individuals will have changes in awareness and stay focal non-motor seizures typically have other symptoms that happen first previously known as an aura this could be changes in sensation in emotion thinking or experiences there are six main types of generalized seizure the most well-known is the tonic clonic seizure previously known as grand mal here the seizures present with a contraction of the limbs followed by limb extension and arching of the back usually lasting 10 to 30 seconds at this stage you may also hear what is known as the ignell cry which is a sound produced due to the contraction of the chest muscles following this the limbs may begin shaking and in total a tonic chronic seizure would last around two to three minutes tonic seizures as the name suggests present with increased tonicity meaning a sustained contraction similar to the start of the tonic clonic seizure in this instance cyanosis may be seen if the seizure affects breathing clonic seizures are another type characterized by the shaking movements we just mentioned myoclonic seizures feature muscle spasms either in select muscle groups or across the body generally absent seizures are another type previously known as petite male which may have little to no motor involvement and the individual does not typically fall over these seizures typically last around 10 seconds atonic seizures are the sixth type which usually involve bilateral loss of muscle activity for more than one second if a seizure lasts for more than five minutes then it is termed status epilepticus and should be treated as a medical emergency this usually involves airway management and medications such as benzodiazepines phenetoin and phenobarbital following a seizure there is the post-ictal phase which precedes a return to normal consciousness post-dictal periods can last from minutes to hours and usually feature confusion tiredness headaches and difficulty in speaking up to around 10 percent of people also experience psychosis and many individuals have some form of amnesia seizures can be divided into provoked and unprovoked seizures the pneumonic vitamins can be used to remember the causes of seizures v is for vascular causes including hemorrhagic and less commonly embolic stroke although seizures are often a complication of embolic stroke we also include hypertension here both as hypertensive encephalopathy and as eclampsia in pregnancy i is for infections which includes meningitis and encephalitis while t is for toxins which includes drugs such as alcohol and cocaine as well as overdoses but also includes medications such as antidepressants and antipsychotics a stands for arterial venous malformations and other structural abnormalities like space-occupying lesions a will also help us to remember autoimmune conditions like vasculitis m is for metabolic causes such as hypoglycemia hypo and hypernatremia and hypocalcemia m will also help you remember multiple sclerosis the second i is for idiopathic seizures and n is for neoplasms as tumors can also cause seizures s is for stress which can not only be a trigger in epileptic patients but can also predispose to developing epilepsy in the first place in terms of a diagnosis the history of the seizure by any witness is of course valuable in identifying the type of seizure present as well as the postdictal state a history containing drug or alcohol use is also valuable on the physical exam presence of signs such as tongue lesions may point in the direction of a seizure and keep in mind that patients may have sustained injuries during the seizure for example a shoulder dislocation if a provoked seizure is suspected investigations would include ruling out the causes such as blood sugars for hypoglycemia blood tests for the metabolic causes and a ct or mri of the head these scans are often recommended in the first instance of a seizure in order to exclude structural causes a lumbar puncture may be useful in some cases when an infection is suspected but this is not routine electroencephal are often used when an organic cause has not been identified and to investigate epilepsy prolactin has also previously been used as a high level may indicate epileptic seizure rather than psychogenic seizure however a normal prolactin level does not exclude an epileptic seizure as for management during the seizure any hazardous objects should be removed from the vicinity to avoid any injury during the seizure and following the seizure the individual should be placed into the recovery position to prevent choking and of course appropriate airway management should be taken if the airway is compromised the first line pharmacological therapy is a benzodiazepine often lorazepam or diazepam a second dose of benzodiazepine may be given after 10 minutes and if this has not resolved the seizure then barbiturates or propofol may be used second line is phenytoin which will involve a loading dose followed by a lower maintenance dose patients then should generally be referred to specialist clinics for follow-up and an anti-seizure medication may be started such as sodium valproact lamotrigine or levotyracitan