Management of Pediatric Medical Emergencies in the Dental Office
Grand Mal Seizures

Grand mal seizures (tonic-clonic seizures) are the most common form found in epilepsy. They can also be brought on by cerebrovascular accidents, meningitis, encephalitis, drug withdrawal, photic stimulation, fatigue and intoxicants. The entire seizure may be broken down into prodromal, preictal, itcal and post-itcal phases which last no more than 5 to 15 minutes. However, it may take up to 2 hours for normal, preictal cerebral function to return. A grand mal seizure that lasts for hours or days is termed status epilepticus and can lead to death if not managed.

In the prodromal phase the patient may exhibit changes that may be evident only to a relative, such as increased anxiety or depression. A patient with a history of seizures may recognize the development of an “aura” consisting of olfactory, visual, gustatory or auditory changes. If the aura is noted by the patient or the dental staff, treatment should be terminated immediately before it progresses to the preictal phase.

The preictal phase is clinically manifested by:

• A loss of consciousness.
• If standing, falling to the floor (most prevalent time for injuries).
• Myoclonic jerks.
• Increase in heart rate and blood pressure.
• Diaphragmatic muscles go into spasm.

The ictal phase (tonic component) is clinically manifested by:

• Alternating muscular relaxation and violent contractions.
• Frothing at the mouth due to mixing of saliva and air.
• Bleeding from the mouth due to biting the lateral borders of the tongue.
• Lasting 2 to 5 minutes.

The postictal phase is clinically manifested by:

• Tonic-clonic movements cease.
• Breathing returns to normal.
• Consciousness gradually returns with disorientation.
• Relaxation occurs.
• Muscular flaccidity resulting in urinary or fecal incontinence.
• Total amnesia of the seizure.

Emergency Management

Should a patient exhibit a grand mal seizure, the following steps should be taken:

PRODROMAL AND PREICTAL PHASE

• Recognize aura.
• Discontinue treatment and move bracket table and instruments out of the way.

ICTAL PHASE

• Activate the office emergency team.
• Position the patient in a supine position with the feet elevated or roll patient on their side to prevent aspiration.
• Protect the patient from bodily injury, however do not place objects in the mouth to prevent soft tissue injury.
• Assess and perform BLS as needed.

POSTICTAL PHASE

• Administer oxygen.
• Monitor vital signs.
• Reassure patient and permit recovery.
• Depending on the patient’s history and if accompanied by an adult discharge patient to home or to the hospital or physician.

If the seizure lasts more than 15 minutes:

• Activate EMS.
• Assess and perform BLS as needed.
• Protect the patient from injury until EMS arrives.
• If available and the staff is trained in venipuncture, administer an IV anticonvulsant.
  • If intravenous (IV) access is available administer diazepam (Valium) IV:
  • Child up 5 years 0.2-0.5 mg slowly every 2-5 minutes with a maximum of 5mg.
  • Child up to 5 years and up 1 mg every 2-5 minutes with a maximum of 10 mg.