Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everyone. Sorry for that. We'll start in just a couple of minutes. Ok. Can everyone see my slides and can everyone hear me? Just a simple? Yes, in the chat box would be great. And then we'll start in just like a couple of minutes. Awesome. Thanks Nico. Uh I'll just get everything ready and we can take it from there. Yeah, two. Ok. So, hi, everyone. I'm Natasha. I will be speaking to you guys about um, seizures coming from an A&E point of view. Uh Just before we start, I just wanna say extremely. Thank you. This is my last session for this series and our final session will be next week where it's recognizing the sick child where we go through a plethora of different cases under pediatric A&E scope. And so with that further ado we'll start, I've got my ipad here on my right. So I'm looking, I'm just looking at the chat box similar to all our previous sessions. Just if you have any questions. If there's anything bothering you, if you wanna answer, especially, please answer during this entire presentation, I can see your answers and we can discuss. So we're gonna talk about seizures and starting with some of the learning outcomes that we're gonna try and gain from the end of this presentation is to recognize the different presentations of seizures. I want you to be able to initiate the necessary acute management, being aware of the very common differentials when the seizure presentation come into mind and understanding your relevant investigations and knowing a little bit and we'll touch a little bit about the long term management. So we are going to start with a 21 year old male who has come in with loss of consciousness. His name is Morty. So this is all, you know, from a nursing point of view. So you've gone, you've gone to see him. He's in one of the little day rooms. So you just bring him aside from the waiting room and you talk to him inside one of these rooms that is not monitored and you're querying whether he had a seizure. Why? Because he was brought in by ambulance. He was f found on the floor outside his university by his friends. He reported fitting for about a few minutes and then everything resolved in itself. He doesn't really remember what's happened whatsoever. He feels a bit drowsy now, feels a bit sluggish and tired and he doesn't know whether he's hit his head. He doesn't even know how it happened, but he's got a bit of a mild throbbing headache and he's got a bit of nausea and vomiting while he was in the ambulance. And this is the first ever episode where something like this has ever happened to him. Ok. So this is the information that you have. What are your differentials? No, a little bit unlike the other presentations. I want you guys to really respond to me in the chat box, you and I are going to have proper interactions. So all you know is that this person's been found outside on the floor loss of consciousness. Someone has queried that he's petting doesn't really remember what's happened. What do you think this could be? Any ideas? Any suggestions? Got a 21 year old at Uni Shilling hanging out. Yeah. We think it's a seizure. I agree. Brilliant. Someone's thinking about syncope. Great. Can anybody else uh think about other things that you are querying? So for instance, Vas Aagl. Yeah. Yeah. Vivagel. Syncope. Brilliant, beautiful. And if you're talking about syncope and basa vagal, we're thinking about heart underlying problems. Yep, hypoglycemia. An absolutely easy one that can actually mimic a query seizure. If you're thinking about heart, you're thinking about underlying pathology. Maybe if somebody has a particular rhythm, maybe like an arrhythmia. Yeah. Drug related. 100%. This is something that you always need to think about. Is it drug related? Is it, you know, alcohol related? Are they taking any medications to have caused this? Go on? We'll try and get one more one more. And then I can leave you guys alone. What about something that is more infection related? Can anybody think of anything? Maybe like a, maybe like a brain infection? You were like the lining of the brain infection? Do we have any takers? Meningitis? Yeah. Yeah, exactly. No, thank you. So we're thinking about query meningitis, query encephalitis. Um Atypically you can think about things like your migraines. You can think about your hemiplegic migraines. Oh, yeah. Beautiful. Somebody has already said phal. Yeah, sorry to cut you off that. Yeah. So that's all great. So we have a few differentials here. Now, this is just for us to understand a little bit about epidemiology of seizures in itself. How many people do you think can have a seizure in their lifetime? Just random guess. Go on. I know there's more of you. We can definitely answer even if you don't know the answer to it. Just guess it's all right. Oh, we split same about one in 10 people can have seizures. So it is pretty, pretty common. Now, we're gonna talk about these two terms interchangeably and we're gonna talk about why, but how many people can develop epilepsy in their lifetime? Yeah. Go on. Oh, I've got split votes over here. It's interesting, isn't it? If you think about how common it is a person can actually develop a seizure. Now, when you think about a person developing epilepsy, the answer is actually one in 25. Um So uh at a quarter of a population, if you think about it, that could develop epilepsy and how high those rates are. But now coming back to Morty and all of your differentials over here, we've got syncope huge mimic and it is extremely important to try and rule out because most of the times when somebody's coming in with a complaint of loss of consciousness, what you're trying to thread out from this history from this examination is, is it query seizure or is it query syncope arrhythmias is where I was going along? Do they have an underlying arrhythmia and need it to have caused them to sudden loss of consciousness hyperglycemia. Someone has rightfully mentioned alcohol, drug intoxication or even withdrawal. Uh Somebody mentioned meningitis, encephalitis, panic attacks with hyperventilation can present as again, atypical ti a atypical and again, hemiplegic migraines. Now, before we move on, there's something that I wanna ask you because I've mentioned how similar the mimics are between syncope and seizures. So if I were to ask you, what is the biggest difference between syncope and seizures? Oh, so Asher, the answer for the first one is uh one in 10 for seizures. But now coming to my question is I want you to understand and I want you to try and answer what is the biggest difference between syncope and anesthesia? Do you think? Is it the prodrome? Is it a postural element? Is it a post ictal period that you get or is it tonic clonic movements? So it is quite interesting because they can, they're actually very intertwined in between each other and symptoms can actually be interchangeable. But realistically, the biggest difference is your postictal period. In syncope, there is no impaired awareness. After the loss of consciousness, they regain consciousness and they are alert, there is no postictal period. You'd be surprised to say that there is prodromes in both that feeling a sensation or any early warning signs between. There can be a postural element in both, particularly in syncope, not always in seizures, but postural element tends to just be the cause of syncope. Uh Tonic clonic movements can happen in both. They can be a little bit jerking even in a syncope. So it's just good to know. Now, coming back to Morty here, we're gonna continue our history cos I was a bit disjointed. He's otherwise fit and well in himself. He's a 21 year old. He doesn't take any medication. He used to use some inhalers as a child. He doesn't anymore. He has no known drug allergies. Uh His granddad had a lot of fits. He's a bit of a weird character but he just doesn't know what it was or what it's related to. He is a university student who drinks socially and he beeps. No, my next question for you is with that information. Are you satisfied with my history taking, sorry, just making a pole really quickly. So that's the amount of information that you have. Are you satisfied with it? You have a little bit of me telling you that he was found by an ambulance. He was sitting for a few minutes. Completely resolved. He's a bit sluggish now and this is his remainder of his history. No. Ok. Well, what kind of questions do you have for him? What do you want to know? It's your case, your history, your patient, any burning questions you have in mind for him? Oh, some people were slightly satisfied. Yeah, fair enough. I did cover a few things. But do you have any other questions that you'd like to know prodromal symptoms? Yeah, I want you to ask a few prodromal symtom. I will cover this a little bit. Need more on the current presentation. Exactly. So, do you mind telling me I should because you volunteered now or do you want to know about the current presentation of the seizures? What exactly? Or this query loss of consciousness episode? What information are you trying to seek from him also? Because he doesn't remember what's happened? So, what do you do when the patient himself doesn't remember what's happened or what's going on during this loss of consciousness? Don't worry. There's, there's a, there's a help button whenever you want. Um, who is the person that you go to or if they are around when the patient has gone? What's the, is it after an event? Who saw this first. Yeah, exactly. And where I think we both of us are trying to go through. Is there, is there a collateral history? Yeah. Um, who exactly saw it? What did they witness, um, any symptoms that you guys wanted or signs that you guys wanted particularly to find out whether he did anything at all? Drop it in the chat box. I want you to think what is it that you're looking for that would make you think that this is more seizure? Oh, perfect. Yeah. Yes, I want you to know whether something has happened before, during and after. Those are key key words. Any witnesses? Yes, are so beautiful. Well done. Any tongue biting. Yes, I want you wanna know whether there was any tongue biting. Anything else that you guys can think of? Apart from tongue biting. Come on lip smacking. Yeah. Optimisms. Incontinent. Beautiful. Anything else? Anything about the movement in itself that you would have done any frothing of saliva? Yes. You want to see whether there was anything around IPs movement? Yeah. You wanna see the type of movement that he was doing? That's what we're gonna talk about. You wanna see whether it's tonic, clonic. Absolutely. Going thumbs up to everybody well done. What about what we've discussed earlier? The differences between syncope and difference between seizures. What's the period after that? I want you to be mindful of what is it called that period where they can be a little bit confused, tired sluggish postictal period. Yeah, exactly. I want you to always remember that because that's a huge part of the key history that you need to actually find out. Whether is that the difference that would kind of give you an underlying impression of if this is a seizure or is this just something else underlying it? So just to add on these are a few different things that I want you to think about? Well done. You guys, honestly, thank you. Thank you very much for participating. We've got plenty more of these questions throughout this session. So as someone has rightfully said, somebody has lost the consciousness. So I want you to find out what has happened before. Were there any prodromal symptoms? Were there any triggers? What happened during? Were there any tonic clonic movements? Were there any jerking? Was there tongue biting? Was there eye up rolling? Was there any incontinence? Was there? How long did it last for? And what happened after? Did they immediately regain consciousness? Did it take them a while? What were they like afterwards as well? Did they get that by themselves? Now, the fact that they've lost consciousness, where have they done this on? Have they done it on a nice cozy couch? Have they done it on the road? Did they have a head injury? Have they hurt themselves elsewhere? Are they bleeding from somewhere? And a collateral history? Like someone has rightfully asked whether there were witnesses. Was there someone with them? Can they explain what they saw to us? Because that would really help us tease out information about what we think even happened. Was there a postural element whatsoever? Are we thinking that this has got to do with an element of postural hypertension at all? Was there a postictal phase that we're thinking about and symptoms? Like people have lovely, like beautifully mentioned. Were there tonic clonic movements or were there a different type of movements? Incontinence, tongue biting? Was their awareness impaired? Were they completely conscious or were they actually talking to you during this point in time? Were there any triggers? Did, did they not eat? Did they have low BMS? Are they sleep deprived? Are they stressed? Was there any use of alcohol, any drugs, any medication that they are taking to have precipitated this and finally any neurological symptoms? So any new focal deficit, any new altered mental state? These are all things that I want you to find out and talk to them about. Now? Beautiful. You've taken a great history. Now you wanna examine them. Now, what do you do to examine someone from? A&E? It's been a huge series and I want you guys to tell me the answer. How do you examine someone in A&E? Ironically, I've given you the answer, but that's ok. Well, that's the method of ex doing a physical exam on someone an at E assessment. Yeah. Beautiful. That is what I want to hear. So get the observations. His morty observations are perfectly fine. His airway is patent. His chest is clear, warm peripheries, hot sounds fine. No added sounds. His pulse is strong and regular. His calves are soft, nontender. His G CS is 15 out of 15. His abdomen is nice and soft. That's great. I've done my at E So what's missing is anything missing? Is there something else that you want to examine or have I covered it all? Blood glucose? Yeah, we wanna do a blood glucose. We're going into, we're going into investigation shortly. But is there something that you want to examine? Is there an examination? Focal point of view that you want to do? Yeah, it falls under DNE sinois. Yeah. You wanna, you wanna definitely check to make sure that they're well perfused. We kind of do that under C under the D when we think about G CS 15 out of 15. Yeah. Beautiful. And they go, you got it. Thank you. Absolutely great. You wanna do a neuro exam. A neuro exam is so important and sometimes gets overlooked. Although it is part of your at E sometimes we just tend to do it when it's necessary. Now, inspection, you want to look for scars, any wasting of their muscles, involuntary movements, fasciculations and tremors. Ek Metics is always a great refresher. Just use them very quickly. You wanna check for their tone, their power, their reflexes and their sensation how their coordination is. And for cerebellar signs, I just use Danish acronym dys dios ataxia, nystagmus intention tremors, any slurred speech or hypotonia, a cranial nerve examination and a silver trauma, which we've covered last week. And this is basically an assessment where you're checking all the bony bits of your body to ensure that there is no injury, especially if they have lost the consciousness somewhere outside on the road and you want to ensure that they haven't, you know, hurt themselves, broken any bones or caused any intraperitoneal bleeding whatsoever. Now, investigations as someone has rightfully mentored BMS, what we're gonna do, we're gonna do a few things for them. We're gonna do an E CG why we're looking for arrhythmias. We're looking for just any signs of why they could have collapsed. We're gonna do bloods. Anybody wants to tell me the different types of blood sets that you want to order for this particular person for Morty go on. You can show off. Yeah, use the knees and we'll talk about the causes and why. But you want to definitely look at the electrolytes. What else? Say them all to me. Go on. Don't be shy. E eg Yeah, we're going to E EG in a second. All done. Ok. But what about bloods? Yeah, you wanna do a V VG? What are you looking for in a V VG? Yes. What are you looking for on a VBG since someone has beautifully mentioned hypoxia or lactate. Yeah. So you're looking for the lactate on the G so blood, full blood count enase LFT S your bone profile that cover you your calcium and your phosphate. You wanna do magnesium as well and you want to do a CRP and a glucose as well. V VG, you're particularly looking for a lactate, especially in a generalized chronic tonic seizure. Your lactate will be acutely decreased. You do not see this rise normally in a person that's coming in with the syncope again, it can change because if you have an elderly person that's a bit dehydrated or septic, your lactate can increase in that as well. So there's always exclusions toxicology. So your ethanol, your drugs, any suspicion of overdoses, things like that, you can determine and decide if you want to do something, then urine dip. Why is this necessary? It's just because in case you're thinking about a pregnant person doesn't apply to morty. But if you're thinking about it comes, yeah, imaging. Now, for imaging in Ed, what would you want to do for them? What would you consider doing a CT head? A CT head with contrast, an MRI head or an MRI head with contrast. What is the imaging of choice from an ED perspective? Oh, we've got plenty. So from Ed, it is act head without contrast, you're looking just for a simple plain CT head when you're thinking about when they go into the medical unit and you're thinking about an MRI head. It depends on what you're querying. Then we've got, this is most likely done after they get moved from Ed to AM U your medical unit for a lumbar puncture. And as somebody has mentioned, e eg so very quickly, what exactly is a lumbar puncture? A lumbar puncture is a, a procedure that is done where a spinal needle is put in between your L3 and your L4 or your L4 and your L5. And this specific location is because it is way below your Conus medullaris basically cause that terminates at the L1. And what you're trying to do is you're trying to achieve your CSF fluid and you're taking it off samples, what samples you are taking it off for and sending it off for. You've got four different tubes. Your first tube is your cell count and your differentials, glucose and protein, gram stain culture and sensitivity. And another cell count and differential. Again, these are things that you are not expected to see just as a junior, but you're always more than welcome to try and as you progress, you'll be able to carry them out yourselves. You don't really need to extremely understand interpretation of CSF fluid, but it's good to understand what exactly you're looking for. In this case. Obviously, just focus on different types of meningitis, different types, whether it's viral, bacterial TB and what is normal looking CSF, you're looking to see about the amount of white cells. What's the predominant white cell type? Obviously, if there are red cells requiring something like a subarach and if there is any protein and obviously opening CSF pressure can just vary a little bit, but that gives you a bit of an indication. Now, e eg is something that someone else has mentioned. Normally it's done after advice from a neurologist and we will talk about the different types of seizures later. But what you can see is that an E EG is basically getting your brain wavelengths. Yeah. And how it actually helps is that it records electrical patterns in your brain and it can help support a diagnosis of epilepsy and it can also help determine the risk of seizure recurrence in a partial seizure. E eg just here at the bottom. You can see it just affects one part of the E EG sequence and in generalized it is a complete through and through um complication of your whole eee eg wavelength. Now we're gonna talk about management of a first seizure in EED. And this is a the protocol that has actually been done by our camp, your Royal College of Emergency Medicine. I've just made it into this flowchart. So you've got a patient with a suspected first seizure. This is what you need to do to ensure that they're suitable for this specific protocol driven investigation. For Act head. They need to be over 16 years old suspected for a first seizure, query, convulsive in nature, they should not be in status epilepticus and the seizure is not related to a head injury or eclampsia. So, if they meet those criterias, use this flow chart, the next question that you need is do they need neuroimaging? This is between a yes and a no. So do they need neuroimaging? If there's a yes to any of the following, then yes. So basically any new focal deficit, are they confused? Sluggish tired? Do they have a fever or a partial onset seizure? And if they have any history of any one of the above, it just increases their risk. Do they have any history of a anticoagulant or bleeding? And if you wanna make sure that follow up cannot be ensured, so then you decide whether it's yes or no and then you can risk stratify them into high risk to being admitted or low risk into being discharged. Now, how you risk assess them now has made this into a very double negative uh type of format. But all you need to know is that if they are high risk, they are considered high risk if obviously they've had um a more complex fit without full recovery, if they have neurological deficits and if they have abnormal initial investigations, the rest of the criteria, if it's a yes, if they've got, you know, history of suspected alcoholism, poor social circumstances and basically no supervising adult to bring them in it me leaves them in a bit of a moderate conundrum. And if they don't have any of those, they are basically low risk. So coming back to our risk stratification tool, if I lost, I've lost my cursor. Sorry. There you go. This gives us an idea. If they are high risk at all, you would admit them to your medical unit if they are low risk. And I want you guys to pay attention here cos I will test you on this in a few minutes. I want you to be able to give them discharge advice and query arrange outpatient neuroimaging. I will be very honest with you. And in this day and age, most of the time, most patients that have come in with a query for a seizure will be imaged in Ed and arranging follow up for a first fit clinic. So those are the things that you need to be aware of for a discharge. So let's go into discharge. So what do you need to tell them safety netting advice? What does this accomplish? Number one, what to do in the event of another seizure? So this is what you can tell them. Obviously, especially for a person that is staying with the patient. That's anesthesia is to stay with the person and start timing the seizure. Obviously, turning them into the side. You're basically trying to give them advice on what the recovery position is and being mindful not to try and give them anything orally, do not restrain the patient and just stay with them and the warning signs as to when to call 911. Next thing, avoid things like bats, swimming heights and operating any heavy machinery and giving them a leaflet on discharge so that they can summarize and read all of that together. The next thing is the outpatient imaging. It's on the protocol, but realistically with you most of the time they will be, they will receive act head in the department and referral to the first f clinic. So this is what it looks like in my trust. It is basically just a word document that you have to fill out. This first page is us as a doctor that fills it up, which encompasses your past medical history. A little bit about what we've just discussed. Was it witnessed? When did it happen? Were they provoked by alcohol or drugs? What is their EC G? Have you advised them not to drive, avoid height shower, then bathe? Well, what you would notice is that these two pages are so detailed from a first hand witness account where it documents and wants you to know what has happened before the collapse. What were they doing? At what point were they, were they exerting themselves? What happened at the start of the collapse? How did they, you know, present? How long was it for? Um what were they doing? Could you do anything to them, for them to, you know, gain consciousness. And at the end, so very similar signs of what we've already discussed. And next is driving, why? Because you, they are not allowed to drive until they have been reviewed by a specialist. And they need to inform the DBL A. Now, if they've had a first seizure and they were aware of it, there's, they're still not allowed to drive and it can be for up to six months. If they have had a seizure with their consciousness, impa that can be six months up to a year. And it depends on what point the neurologist has seen them and what review has been happening and that's obviously a lot worse if you're in a group two category in the UK for driving. So now we're gonna talk about management. We're going to go back to Morty over here. So, Morty abs are all stable. You've done a physical examination which shows that he has no neurological deficit. His ecg is normal sinus. His bloods are completely pristine. His ct head is normal. So my question is, does Morty need to be admitted or are we going to discharge him? Seven, let's just look at all of those things for a second and I'll bring up the risk assessment tool. What do we think? M he has had a simple fit with a full recovery. He's had no neurological deficit, normal initial investigations. You have no suspicion that, this is alcohol. He lives fine. He's got a grandpa that looks after him and his family does look after him and if he needs any follow up he would come back. So, what do you do? Yeah, that's good. Have a, have a think, look at this risk assessment too. He has absolutely no high risk qualities and absolutely no moderate risk qualities. He is a low risk patient and if he is a low risk patient, that means da what do we think? He's an absolutely low risk patient in himself. Yeah, we can discharge Morty. That was great. Now you are going to discharge Morty. I am very proud of you. And I told you I will ask you this what a safety netting advice. What are you gonna tell him? I want you to recite to me the three things anybody remember, Angus go on. No, I'll wait for one and I will persevere. I'll go on through it. Yes. Thank you. What to do it again. Driving advice. Oh, somebody's already remembered it. So yeah, safety netting advice. You want to refer him to the first fit clinic? No, but beautiful well done seizure leaflet and most importantly from this list, somebody has already mentioned beautifully. Roa is no driving. It is so important because by dangerous equipment, swimming. Absolutely perfect. Perfect driving is so important to address in these loss of consciousness episodes in these seizure episodes because the risk of death has increased tremendously, especially if they continue to drive or if they're not warned about it. Now, we've talked about seizures. Let's understand the definition of it. Technically, a seizure, in simple words, is a single occurrence of jerky movements that is characterizing a seizure. What it is is a Parimal motor sensory or autonomic event that happens because you have abnormal, you have too much. You have synchronous electrical discharges from your neurons, basically firing about in your brain. It can last for under five minutes. And if it's over five minutes, it's known as status epilepticus. Next epilepsy, these words get thrown about and it's good to understand the definitions between it. Epilepsy is a chronic disorder, chronic disease of the brain where it predisposes a patient or a person to having recurrent unprovoked seizures. That means seizures that are happening and pleural without a clear triggering cause. We have the il ae. This is the international league against epilepsy that have a criteria to meet before you diagnose someone with epilepsy. The first one commonest and easiest one to remember is a minimum of two unprovoked seizures 24 hours apart from each other, the other one is one unprovoked seizure with the probability of further seizures because the recurrence of that with two unprovoked sei seizures are about over 60%. And the third is diagnosis of an epilepsy syndrome. This is when we're getting into niche neurological things such as West syndrome. Uh Lennox guest out syndrome, juvenile myoclonic epilepsy. I don't expect you to know all of that. I don't even know all of that, that it's more for neurologists. But these fancy syndromes do exist. Now with that said, let's talk about the different types of seizures. Now, we've got generalized and focal and just as the word explains it, what is it? A generalized seizure basically means that the seizure is arising from both the hemispheres of the brain at the same time. And a focal seizure just means that this focal point, it's arising from a specific area of a focal point of your cerebral cortex. Great, you have two different types of seizures. Now, what I need you to remember is from the focal point, it can actually progress into both your hemispheres and it becomes what is called a secondary generalized seizure. So it can change. And that's really important for you to understand. Next is understanding the breakdown seizure types is broken down into first the generalized seizures where it happens from both hemispheres of your brain that's broken down into a motor function. Is there a motor element? And that is into tonic clonic, myotonic, a tonic and then it is broken down into non motor and nonmotor follows into absence. Then we've got focal which is the single like focal point or one point of a hemisphere of your brain. And this is broken down into, were you aware during it or was your awareness impaired? And then we've got unknown seizure types which is also broken down into motor or nonmotor and unclassified. Now, I mean, this little flow diagram cos it looks a lot better than this one to me. So this is the International league against epilepsy that has classified seizure types. Now, it basically just confirms whatever I've just talked about, but in more detail, but it's obviously really good. If you wanna do some light reading, you can definitely go on their website. Now, what we are gonna focus on in the next couple of minutes is generalized and focal. So let's start with generalized. So, generalized seizures happen in both your hemispheres of they arise from both hemispheres of your cerebral cortex. Now, in generalized seizures, it almost always causes impairment of consciousness. That means you've got an element of loss of consciousness with it almost. OK. So we're going down our motor route where it affects your motor ability. Now, we're gonna go into tonic clonic. So what is your tonic clonic? So your tonic phase starts with this sudden stiffening of your muscles and clonic is that rhythmic jerking of your muscles? And most of the time is obviously combined together where you get a tonic clonic phase. Now, this is a very typical textbook presentation of a seizure. What I want you to remember and what we've already discussed in terms of the symptoms of it is the contraction of muscles that happen with this. And that's how it like relates to the symptoms. So your ocular muscles causes the up rolling of your eyes, your oropharyngeal muscles, as someone has rightfully said, causes that pooling of secretions that frothing that you can see your jaw muscles become tight and that's how you can bite your tongue, vocal cords. This is how sometimes people can actually be screaming, crying or even grunting during these. So clonic seizures. Next is our urinary fecal incontinence and also that postictal phase that we've already discussed with absolute detail. Next. Oh, sorry guys, it's a bit messier. We are going into our myoclonic. Now, myo tens for muscles. This is a sudden rapid muscle contraction where most of the time actually, your awareness is not impaired. The difference between tonic clonic and myoclonic is your rate of your contractions. So for a myoclonic, it is basically the rate of contractions is 0.1 seconds. And tonic clonic is 1 to 2. These typically occur in the morning and they're triggered by simple things like stress, sleep, deprivation, et cetera. So we'll see whether this works and hopefully you guys can see a little clip. Does that make sense? I'll just show it again so everyone can see it. Oh, brilliant. So that is an example of myoclonic. Next is atonic. Atonic basically means no muscle tone atonic and this is basically a sudden loss of postural muscle tone lasting for 1 to 2 seconds. So it is basically someone actually just dropping and collapsing completely out of the blue. Uh This is extremely common um in Children as well when it's diagnosed, it's like Lennox Guest Out syndrome and it's known as drop attacks. So, very similarly, we're gonna watch a very quick clip again. We'll watch it just again to make sure that's working. Ok. Hopefully that was all. Ok. And people could see that no non motor where we don't have a motor element of your muscles is absence, Jesus. And when does this come on? It is a very sudden brief loss of consciousness from seconds to minutes without any change in your muscle tone. As you can see in this child, very common in Children and adolescents, it can happen almost 100s or dozens of times in a day. So their body doesn't change, but they are having episodes of where they are completely vacant, they look like they're dazing and it is extremely common to be misdiagnosed as ad HD because teachers will think that they are daydreaming, they're not paying attention, they're losing focus. So hopefully, that makes all sense when we've talked about generalized seizures. Next, we are going to be talking about focal seizures where they happen in a focal part of one hemisphere and how we describe them is they are broken down into aware and impaired awareness. Now, as it, as you've just said, obviously, if they are aware during it, they do not have a post ictal phase. But if their awareness is impaired and has been affected. They will have a post ictal phase. What a focal seizure comprises of is either a motor sensory or even autonomic uh different types because it depends on the area of the brain that is involved wherever the seizure is, that's what can actually present as. So in that sense, for example, a motor would have, you know, a cl a tonic like a tonic clonic type of, you know, jerking movements. Whereas sensory could be, if it's in the occipital lobe, you can have just flashing lights. So with that said focal seizures can start with subtle neurological signs like auras. And this can be things like um automatisms where it's basically chewing lip smacking as someone has mentioned before, rapid blinking of the eyes, um unusual odors. Some people have mentioned like Carne a rising sensation in their abdomen or even that feeling of dread, fear or Deja Vu. And another very common thing that people can experience after a focal seizure is Todds paralysis. And this is a temporary paralysis of the affected limb now very quickly because we've talked about focal where it affects a part of your brain is a type of seizure that you can you or a type of symptom that can actually arise. So we talk about the red part and this is basically the front of our head. So your frontal lobe, it controls things like your concentration, your planning problem solving your motor control, which is what I'm talking about. A little bit about your speech. And even that smell, we talk about the front bit of your head, which I like to call your, your pa parietal lobe, the parent of your head. And this controls things like your touch and your pressure and your taste and a bit of your body awareness. Your sides are your temporal and this is your hearing and your facial recognition. We've got our occi our vision. So those flashing lights. So you can see skin till relations, your cerebellum, which is your coordination. And obviously just that's just where we in the keys is. So you've got your language comprehension and your reading. Now, we've talked a lot about seizures. It's really good to talk about the causes of our seizures. So, something that I liked was uh vitamins, which is a very easy acronym to remember. So V stands for vascular. So this is basically your ischemic or your hemorrhagic strokes or basically any bleeding, any venous thrombosis that you can think about any clots, any um vascular malformations, then we have infections like people have already mentioned. So when you think about your differentials, this is what you can think about any causes of these seizures. Your meningitis, encephalitis, your brain abscesses TB HIV, things like your lumbar puncture can help us decide whether this is all related will give us these positives in terms of our results. Um Imaging might help us as well for the abscesses. Next is TT is for trauma. Obviously, if you've got like, uh, proper head injury or any wounds, um, that can cause it, toxins are like what we talked about earlier. So you've got, um, medications, you've got alcohol, you've got drugs. So your toxicology will help us a good history will help us. Now, can anybody give me any medications that they know? So, medications or drugs, anything that you prefer that could maybe induce a seizure or cause a seizure to happen? You don't even need to know the name. That's ok. Maybe like in the class or what they're used for lithium. Yeah. Lithium is a great example. And just as uh Rodriguez mentioned, psychotropic medications extremely, extremely common because of seizure antipsychotics. Yeah, beautiful. So think about your antipsychotic drugs, opioid drugs, um cancer therapy, drugs, um even aminophylline or theophylline. These are very common as well. Next, we've got autoimmune conditions. So your C ns vasculitis, your lupus sarcoid MS, these are all common metabolic is where our bloods come into place. So we've got hypernatremia, hypocalcemia. Yeah, definitely as someone has mentioned hypernatremia and you wanna think about different types of encephalopathy. So if it's apathic, is it coming from your liver? Is it kidney, is it uremic encephalopathy? And the Wernicke's for immune deficiency, is it coming from, you know, history of previous alcoholics? So it's good to think about that. Idiopathic well falls on epilepsy and that's just because a third of epilepsy like causes are unknown. So it just tends to fall there. N is neoplastic. You want to obviously know whether it's this primary or secondary malignancy. And SS is for differentials like for example, your query psychogenic seizures, your query functional seizures, your syncope, which is a huge mimic of your seizure. And something that's not mentioned in this is your for women, especially that are pregnant is query eclampsia because that is extremely life threatening. So it's good to have at the back of your mind. Oh, ok. So we are back at, in case. So you've got the 21 year old male coming in to you for a seizure. He was discharged from ed yesterday by yourself with a referral for the first bit clinic. Oh, that's what he looks like. And you've been asked to see him in recess as he is actively seizing. What do you do? You've got a 21 year old male in recess and you've been asked to see him? What do you want to do for him? Seems like a loaded question. Honestly, I want simple answers. Yeah. You want to know how long is he seizing for? Absolutely. Ah, you guys have gotten it. Yes, I want you to do an A to E that is absolutely brilliant. Yes, I want you to do an A to ei want you to talk to him well done. What is important that you keep count of while he is seizing. What do you want to monitor when someone is seizing any ideas? Time? Oh, excellent. So, he's been seizing for over five minutes and he's still seizing. Anybody. Wanna tell me why this is so important. Why is this called? He's having a seizure and it lasted over five minutes. If it helps, it starts with the letter S status opticus. Yes. Brilliant. What do you wanna do for that? Yes, absolutely. Brian, well done. Rodrigo. Well done, Joanne. Thank you. Yes, he is in status epilepticus. This patient. So what are you gonna do for him? You've said you're at? OK. IV LORazepam. 4 mg. Yes. So status epilepticus, we've kind of covered it, prolonged convulsive seizure lasting over five minutes or recurrent seizures one after the other without any recovery in between. Number one, stabilize your patient. Do your A to E number two. Your first choice is IV LORazepam. If you have IV access, if you don't have IV access, you have your buccal midazolam and your rectal diazePAM. Next, consider your cause. And that's why we've gone to our vitamins. If that does not stop within the next 5 to 10 minutes, give you a second dose of your benzos. So that is your LORazepam again. If that does not respond, then your second line therapies include levetiracetam, phenytoin or sodium valproate. So let's say you've tried levetiracetam loading them with that. If that does not respond, then you can choose something like phenytoin. But please, please please already contact neurology to find out what they would like us to do as well. And if phenitoin hasn't worked, then you can lower them up with sodium valproate, but they should likely be somewhere else. The worst, worst, worst case scenario is when they haven't responded to anything and you're basically putting them into an induced coma to well to intubate or ventilate them while you've stopped them from seizing. So this part is long term management for medication for a seizure. I don't expect you to know this in an A&E perspective, but it's obviously very good to understand what is considered first line for the different types of seizures for men and basically women that are childbearing age and not and for Children. So for the first category for men and women that you know, are no longer childbearing age, most of the time is so in rate, unless it's focal for women that are at childbearing age, most of the time is lamoTRIgine slash levetiractam. And for Children, most of the time is sodium valproate. But always remember for absent seizures, it's always oxy etosuximide. I can never say it. But yeah, now, very quickly, we've got random fire cases and you guys will be done in exactly five minutes. I've got seven year old male Stefan, he's been brought in by his mother. He's had several episodes of loss of consciousness every day for a few seconds. His teacher mentions as he loses focus easily during lessons, he has no postural, like his muscles don't change in that. What is his spot diagnosis? What do you think this is? So, you've got a kid who looks like he's not focusing? Yes. You want. You think that it is absentees? Well done? Absolutely. Great. What's the medical management for an absent seizure? I know. I only gave you two seconds. Anybody remember the Soxamide? Yes. Absolutely brilliant. Yes. So that is etosuximide. Next case, 26 year old male Jacob brought in by his friends after loss of consciousness for about two minutes. Um What they noticed was that he was jerking quite a bit. He was stiff and then his body was jerking throughout. He's very confused. He's sluggish, he's tired. It's about 30 minutes after first presentation of something like this. No alcohol, no drugs, he's fit and well, otherwise, what do you think this could be? Do you think it could be a focal seizure? A myoclonic seizure, a tonic clonic generalized seizure? Yeah, absolutely brilliant. Any differentials for him that you're thinking of anything in particular? Just say one month, we can consider that you guys have learned loads from this presentation. Yeah, hyperglycemia beautiful. Now his ct is negative. Admit a discharge again, I know I don't have all of that risk assessment portfolio, but let's just say that he has absolutely no neurological signs. He's fine in himself. He's got a family um he is doesn't have any complex neurological features. His baseline investigations are fine. Yeah. So actually in this as well, if he's fine in himself and all he is is a bit confused sluggish and tired, you can actually discharge him as long as he meets the criteria for low risk. So, what I was trying to explain is that he is low risk case. Three Megan, 11 year old female brought in by her father, her twitching of her, just her left foot lasted a few minutes. But Megan was unconscious during this and has no memory of the event. She's very lethargic. Now, what do you think this could be? So she is awareness impaired and only one sign is episode of twitching in her left foot. What do you think spot diagnosis would be for her focal impaired awareness? Yes, that's beautiful. Well done. Yeah. Focal because it's affecting only one thing at the minute impaired because she was unconscious. Anybody wanna just guess for Children for medication what it could be the mogen. Look, anybody wanna guess in terms of the pools I see. Don't worry. We only have one case. So I'll be done in just a minute but you guys have to leave. Thank you very much. What do we think? What medication are you gonna give this? G this girl who is 11, who we think has a focal seizure? Yes. So it's actually carBAMazepine slash lamoTRIgine. Uh the one you was again, bananas. So case 4, 24 year old Joanna, sudden left foot or hand twitching just very sudden ongoing for a few months. Her awareness has never been impaired. She hasn't been sleeping. She's stress and anxiety is just extremely rapid contractions of her foot. Oh, hi, Bianca. Yeah, the recording will be made available. You can just access them, they'll be on demand content in probably like two days time and then you can get them up on metal, you'll just search it on the 6 p.m. series. So for Joanna, what do you think this could be? What type of query seizure, myoclonic or focal? Yeah, exactly. Brilliant and differentials. Basically, I'm just trying to get you guys to think whether, you know, query, I want you to think whether it's query, myoclonic or query focal, even sometimes query psychogenic in nature, query, you know, stress anxiety, you know, just basically just normal things that you would think about as well. Medical um medical management for a query, myoclonic seizure in a woman of childbearing age. Ok. So how can we differentiate between myoclonic and focal? It is actually very, very difficult. I will be honest with you. That is why they actually overlap with each other. Unfortunately, a little bit myoclonic can basically just mean just focusing on the muscle twitching itself normally doesn't impair awareness in itself. And it's basically de determined with um EE GS are determined with a neurologist watching, it are determined on the stress factors that are also there. Your focal seizures may have lasting or like prodromes just before. And they would have those atypical atypical things like your auras, uh ch to paralysis, um query automa. And that helps you think that it could be focal. Again, it's not always clear cut. Levetiracetam. Yes. Well done. Nicole. I want you to think that in childbearing age, levetiracetam slash lamoTRIgine. Thank you very, very much guys. Well done. So please please, please, as always, please do our feedback form and thank you very much for our session. This will be my last session. You'll be joining Harry next week for recognizing a sick child. Thank you for joining us. All right, it's epilepsy and umbrella term for seizures or is it a cause for seizures? Epilepsy is a cause of seizures. Yeah, seizures is basically just the phenomenon and you're trying to find out what's the cause of it in epilepsy. You have um you know, you have unprovoked seizures if that makes sense. If you guys have any questions whatsoever, let us know. But um thank you very, very much for everything. Please do the feedback form. I hope that answers your question. Rega Oh, no worries. Thank you guys. I really hope you've enjoyed the series. Please. Please join us for our very last session next week. Thank you and don't forget to do our feedback for me. We really, really can improve based on all of this. And what you guys tell us, ok, you guys, you take care, have a good weekend.