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Okay. Okay. My name is Jeff Lawson. I'm originally retired consultant, pediatrician, uh, and where my areas of expertise included those in dealing with pediatric epilepsy, but you'll notice later weight that I haven't called this lecture. Pediatric epilepsy. I've called that pediatric seizures. The reason for which will become apparent. Why isn't it going that right? First of all, we're going to talk about status epilepticus, which is clearly a seizure type. And it's really important that you know how to deal with this matter as a matter of life support. Um, presuming that you'll be able to get access to this flow chart, uh, because it's recorded. And so I presume that you're going to become if this is going to be available to you. Uh, I thought I'd just go through what we do about status epilepticus status. Epilepticus is a fit which goes on for more than 10 to 15 minutes. The most important thing instead of epilepticus, is trying to limit the length of the seizure. The initial reason for that is the longer it goes for, the more difficult it is to get a child out of continuously having a convulsive seizure and the and the reason for getting a child out of status. Appalachia. Because it's also that if it goes on for more than 30 minutes, then neuronal damage is far more likely. So there is an urgency in trying to deal with a child who is fitting in front of you. So right, the, uh this bar is in the way for me, but it doesn't matter, right? A trial comes in and is fitting. You're going to do first aid. You're going to do a B C airway breathing circulation. You're going to call for help because if you're a junior doctor, you will need help. I can assure you you will need help to, uh, to get drugs. You will need help to be able to manage the situation because it is not straightforward. However, you're the person in the front line and you're there. If the child has been, uh, fitting for five minutes or more, I would suggest the first line of treatment would be buckle midazolam, because getting a cannula into a child is not all that easy. So certainly, if the child has been fitting for five minutes already, I would give a dose of buckle midazolam. Rectal diazepam has largely gone out of favor because it is inconvenient to give. It is embarrassing, perhaps, for older Children to have diazepam, rectally, and so buckle Midazolam is the favored way of giving a benzodiazepine. If you do happen to have vascular access, then you can give your first dose of benzodiazepine intravenously with lorazepam. Please note if the child comes in from home, having been given some benzodiazepine midazolam by the either from by the parent or if they have that at home because of previous fits which have gone on or the paramedic then it is very important to note. One is only allowed to give a maximum of two doses of benzodiazepine. This is for two reasons. One. If benzodiazepine hasn't worked, it's unlikely to work with a third dose. And secondly, the more benzodiazepine you give, the more likely you are to have respiratory depression. So you've given the first dose of Let us say buckle midazolam, and the child is still fitting. Then hopefully in the 10 minutes that you've got between giving that first dose of midazolam, you have got an IV line. Alternatively, course you could be thinking about giving an intraosseous. Does he give IV lorazepam? Paraldehyde is not being used as much now. And this, uh, this this pathway is a little bit out of date for that reason. So you've given buckle midazolam 10 minutes. You've given lorazepam. Now, remember, at this point, you're 10 to 15 minutes into a seizure and you're trying to stop it by 15 minutes. And this is where some of the sums don't Don't really add up. If you've given the lorazepam, then, uh, somebody else should be preparing the phen atone rather than phenobarbitone. The phenytoin dose needs to be calculated, and it's an infusion given over 20 minutes. However, at this point, I would ask you to consider that in many situations, an alternative definite own is available. Panettone has got problems of associated as a complication of arrhythmias. It has to be given over 20 minutes. And so more and more people have tried to use other drugs when benzo tiza pain has not been effective. And so you could really consider not only fen atone If it's not, if that's available, it's a good drug, but it has got a potential problem of arrhythmias, cardiac arrhythmias, but the liver Theresa Tam also know the trade name is keppra or even valproate has been used as an infusion for those Children who have not responded after their medication. Uh, that the lorazepam has been given the next step. If that infusion has not been effective, is with an Innis Etta's present, you can give fire Penton. The airways needs to be made secure with AIPO and having been given. So that's why you should have an anesthetist present. So that's the whole pathway. But this is the simplest way of looking at it. First aid, ABC Glucose first dose of dead Benson has been second one. Then easa uh, use finna tone levetiracetam of alp right? And if that fails at about 30 minutes, or how quickly have been able to go through that that that that pathway fire pen tone with a child subsequently being intubated and cared for possibly on intensive care for a short period until the thigh panton can be reduced because thiopentone is just about 100% effective in obliterating the the excess neuronal activity which is causing the status epilepticus. So that's enough about acute problems and how to deal with status epilepticus. I'll now pass on to saying What is a definition of an epileptic seizure? I've been very careful in my use of words. There, uh, an epileptic seizure. An epileptic seizure is a transient occurrence of signs and or symptoms due to abnormal, excessive or hyper synchronous neuronal activity in the brain. So the important bits of this, which are the important bits I put in separate lines, it's a transient occurrence it doesn't have a child, is not with epilepsy is not seizing all the time when they're having a seizure. It is a transient event, but it is not an e e g diagnosis in as much as there must be signs and or symptoms. Mostly it's going to be a convulsive seizure. But there are many sorts of seizures, like absent seizures, which do not have a convulsive element. But an E e G abnormality without signs or symptoms is not a seizure. It is due to, as I've said, abnormal, excessive or hyper synchronous neuronal activity in the brain. How do they present it could be a federal convulsion, a nonfederal convulsion. It could be vacant episodes. The diagnosis is as yet not defined. So in the classification of epilepsies, the purpose for which is a clinical diagnosis, the International League Against Epilepsy, from whom I took that definition of, uh, an epileptic seizure. More and more, we're trying to use language which is easily understood, using words that mean what they say. Now, if you looked at the International League against Epilepsy, you would confuse yourself badly by trying to learn about pediatric epilepsy through the International League against Epilepsy because they have defined anything and everything. This is a very basic talk about primary epilepsy, because as medical students, I don't want to confuse you with unnecessary detail. What is true is that there are three main forms of epilepsy. Primary epilepsy that's generalized epilepsy affecting the whole brain, focal epilepsy, at least starting in only one hemisphere, and then a few rare forms of NKF allopathic epilepsy like West Syndrome, also known as infantile spasms. The International League against Epilepsy, however, have tried to make this a little more easily understood. So a seizure begins either with a focal onset, a generalized onset or unknown onset, and you'll see that in both this and the types of epilepsy. Unknown is an unfortunate necessary part of this. Because so much about epilepsy is not understood. I'm trying to give you the basics of what is understood. The epilepsy types are mainly generalized in Children, less frequently focal epilepsy. Sometimes you can have generalized and focal epilepsy in the in the same syndrome, and some are very difficult to define, therefore unknown. And from that 1st and 2nd line of the seizure type and the epilepsy type, you can define epilepsy syndromes. The etiology of epilepsy is it is thought, mainly genetic, but it can kind of infectious causes or metabolic causes, and I'll come onto those in the investigations. In many forms of epilepsy, there are co co morbidities. This is how the International League Against Epilepsy have classified seizure types, and it's simplest form. It has defined each of those boxes even further, but I don't believe that's helpful if you take generalized onset epilepsy. There are two basic forms. Motor forms of generalized epilepsy like tonic clonic seizures and non motor forms of generalized epilepsy like absence epilepsy, focal epilepsy. There are different features about either being aware, having awareness of of of the event and impaired awareness conscious levels being affected. Focal epilepsy can either be a motor event with, for example, um, shaking of one hand or one leg, or it can be non motor. It can be something like having a funny taste in your mouth or in occipital epilepsy. Uh, flashing lights. Some focal epilepsies will proceed to, uh, affect both sides of the brain to produce a bilateral tonic clonic seizure. So that's what generalized seizures are affecting both sides, both hemispheres of the brain. Focal seizures happen on one hemisphere, and sometimes they can spread and and cause a secondary generalized seizure. But many focal seizures are limited to just one hemisphere. You'll notice in this next slide, I haven't had the classification of epilepsy, I said the classification of convulsions, and this is why I have I labeled this this talk pediatric seizures because some seizures are not epileptic. What I'm going to do now is I'm going to explain to you the forms of generalized epilepsy, then talk about focal epilepsy and talk about probably the most common presentation to my epilepsy clinic, which will be Children who have had non epileptic events. But events which have provoked that concern now before I go to the next slide. Could you just write down in the nice next 45 seconds as many different forms of generalized epilepsy epilepsy, which affects both hemisphere or both hemispheres at its onset? There are six different forms of generalized epilepsy. I'll give you 45 seconds from now. Okay, generalized epilepsy. These are the six types of generalized epilepsy most people know generalized tonic clonic seizures. Many will, of course, have. And I've mentioned it just prior to that slide absence seizures, which is another form of generalized epilepsy, the ones that most people forget about our my chronic seizures and atonic seizures, but as well as tonic seizures, tonic clonic seizures, you can have purely tonic seizures in which Children just become very stiff. You can have purely clonic seizures, but I would emphasize that tonic seizures, chronic seizures and atonic seizures are really quite rare and generally occur in Children with other forms of neuro disability. So I'm going to take talk, mainly because this is basic pediatric epilepsy. I'm going to talk a little more about tonic, clonic seizures and absence seizures. So generalized tonic clonic seizures. You will note that most people who talk about generalized tonic clonic seizures in the clinical setting will not have actually seen the tonic phase. Neither will they reliably get a history of a tonic phase. This is because most people seeing a seizure will be a parent. Will be a teacher, will be. Maybe nobody actually saw it. The point I'm making is that although tonic clonic seizures are the most frequent sort of seizures in Children, the tonic phase is rarely actually observed. Maybe with the second or third seizure. Parents who are prepared and who are looking for a tonic phase may note that it is, as I said, the most common form of epilepsy in Children of seizure type. In Children, it is a syndrome general tonic. Clonic seizures is a syndromic diagnosis when we talk about absence epilepsy, which is probably the second most likely, uh, most common form of of generalized epilepsy in Children. Most will have childhood absence epilepsy, presenting at any time between about three years and seven or eight Juvenile absence. Epilepsy is a bit of an overlap, starts about six or seven and goes on until 11 or 12, and then juvenile myoclonic epilepsy begins at about 12 13 and goes on into adulthood. Juvenile myoclonic epilepsy is more complex and includes not only Micronics. Seizures, which are jerks, would particularly happen in the morning. You also get absences and you also get generalized tonic clonic seizures. So you've got absences, my chronic seizures and generalized seizures. And yet all of these are under the umbrella of forms of absence epilepsy, the difference between childhood epilepsy and the two ones I've just mentioned. Juvenile absence and juvenile myoclonic is on an E e g. There are critical differences of the sensitivity to flashing lights. Childhood absence Epilepsy is not sensitive to flashing lights, juvenile absence and juvenile myoclonic epilepsy. When you do an e e g and you put strobus scopic lights on, then they get an abnormal discharge. And that is the way in which these two syndromes at the bottom of the slide can be differentiated. When we're talking about, uh, generalized tonic clonic seizures and treatment, it becomes important to define a diagnosis of epilepsy and whether or not treatment is needed so most would define epilepsy as being too or more epileptic seizures occurring more than 24 hours apart that is to say, if somebody comes in without a temperature, not a few broad convulsion, and they have two seizures within 24 hours. The Epileptologist was considered that as being one event of epilepsy and wouldn't call. Call it two episodes of epilepsy that becomes important when one is considering the risk of recurrence, because that is what parents want to know. If a child has had one seizure, the chance of having them having another seizure is about one in three. If they've had two seizures, the chance of recurrence is about two out of every three. So the chances have gone up from 35% to about 65% with three seizures within, let's say, six months, the chance of recurrence is 90% 9 chances out of 10. The reason I give you that information is that the dilemma for the clinician and the parent is whether or not to treat the approaches. With one seizure, most parents will say, well, it might not happen again. There's two chances out of three. It's not going to happen again. I don't want to give treatment, uh, accept treatment for my child if it's going to have side effects, so let's just see what happens With three seizures, it's equally clear that most parents will say I would like to have treatment for my child because there's only a 10% chance he's not going to have another fit. But with two convulsive seizures, people are on the fence. And, to be honest with all Children, provide epilepsy. One needs to explain the risks, listen to the parent and counsel them into what they feel is the best solution for them and their child. Talk briefly now about focal epilepsy. Focal epilepsy used to be defined as one which affected consciousness or which didn't whether it was motor or non motor. But now we think about, um, focal epilepsy in by defining what sort of see her it was, and therefore, which part of the brain is most likely to have been affected. These lobes produce different forms of signs and symptoms, so if the focal epilepsy begins in the occipital lobe, then you get flashing lights. If it's in the parry, it'll lobe. You can have unusual touch, sensitivity being noted, or even pain being experienced. A temporal lobe. Focal epilepsy can affect their memory it can affect hearing. But it will also make them, um, suddenly very emotional bursting into tears. Frontal epilepsy. The frontal lobe is involved with high intellectual, uh, events and movements and very typical. A frontal lobe seizure will cause what's known as a an archer, uh, position in which one arm is extended and another is flexed, and it looks as though the individual is going to. It's got a bow and arrow in their in their hands. So these very specific types of frontal seizures are hopefully diff in a bubble to be able to define which lobe. Uh, is it affected? This is clinically useful so that with a focal epilepsy, one would normally be doing a brain image either a CT or, more likely, an MRI uh, CT only in the emergency situation if you really need to know because of some sort of brain injury. But in the outpatient situation, focal epilepsy would be investigated by doing an MRI and telling the radiologist what low of you believe it's being affected will allow them to look at specific parts of the brain more carefully. What investigations might you do in a child who who comes into hospital, I said ABC, including a blood glucose. In case if there it is not known what has caused their seizure, it is a hypoglycemic event. Clearly, if a child is a comes in with a parent and you know the diabetic, it's one of the first things we do is find out what the blood glucose is to correct that sodium calcium and magnesium low levels of each of these ions can cause a seizure. But it is mainly a problem of the under two year old sodium, particularly if they've had diarrhea or if they've been given an inappropriate amount of fluids that doesn't contain electrolytes, Calcium and magnesium. Metabolic problems can affect calcium and magnesium, and that hypocalcemia and have hypermagnesemia can provoke seizures. But that rarely happens in Children over the age of two. An e C. G is important, and I've put that before an E e G. Because an E. C G can be easily done. And if the child has got a cardiac arrhythmia, it is important if the underlying reason it's of the for the seizure is cardiac rather than neurological. It is very important that the E. C. G is done E E. G s are important in any child who has had an epileptic seizure. It is not important if you're absolutely sure there is a diff in a ble secondary cause such as hypoglycemia. Neuro imaging CT scans, with its hydro's of irradiation, is now rarely needed unless it's in the any department where there is an unknown cause of a child having had a fit and who's consciousness has not been regained in the outpatient system, an MRI is far safer and also more helpful. Neuroimaging is not needed routinely for a generalized tonic clonic seizure, and it's certainly not needed for a child with routine childhood absence epilepsy. So the two commonest forms of epilepsy do not require neuro imaging. The exception to that rule is if the child has got a newer disability. I told you there were three main forms of epilepsy by my definition, basic pediatric uh, epilepsy. A basic basic pediatric seizure consideration the third form after generalized and focal seizures. The third, and actually more frequent form of seizure presentation into A and E and to the outpatient department are non epileptic seizures, fee bril, convulsions. The primary problem is the temperature. The secondary problem is a seizure, so we do not consider febrile convulsions to be a form of epilepsy. It's a non epileptic seizure. Vasovagal event syncope, which I'll talk about at greater length, can produce a seizure. The important feature of a vasovagal event offend is that they never produce more than 5 to 6. Jerks never produce an event, which lasts more than 2030 seconds at the very most. They're very short lived, and they recover from them rapidly. The differential diagnosis for a child referred with possible absence epilepsy. Is that there possibly just having vacant episodes? Maybe in school, they're becoming board there. Dead Dreaming. The future, which separates out absence epilepsy from the child. Having daydreaming of vacant episodes is distractibility. In taking a history, you ask what events occurred, how often they occurred, who has seen them in what circumstances. So those open questions need to be asked first. But at some stage, one must ask in this child who's staring. Appearing vacant was an effort made to distract them by physical touch. Sometimes calling their name is not sufficient to bring a child who is daydreaming out of that. So a simple touch on the shoulder to try and distract them is important. Vacant episodes and they're dreaming can go on for a minute or two, whereas Alsons Epilepsy goes on for 30 seconds a minute at the most and is also accompanied by some of the following signs. I fluttering Automatisms. These are very important features in in chartered absence epilepsy, automatisms, our purpose of movements things like stroking their nose, lip smacking, plucking at their clothes. They are nondestructive ble. So hopefully with a thorough history daydreaming Children and Children with absence epilepsy can be easily separated. If there's any doubt, then an e e g can be done. And as I've told you, childhood absence Epilepsy will not have any abnormal, uh, Bren discharges on, uh, strep a scopic light being flashed. But one of the other provoking mechanisms that are employed by an e e g department is hyperventilation and very frequently in childhood absence, epilepsy and, uh, and an absence can be provoked by hyperventilation getting a child to blow on a toy windmill or a piece of paper, um, 50 times blowing hard, hyperventilating, lowering their carbon dioxide levels and thus producing an alkalemia so if you have, um, an Alka lot ick blood, the brain is more likely to be provoked into having an absence seizure, other non epileptic events that I would see in the clinic very much helped by having a video. I would emphasize this, uh, strongly if you're over in the position of assessing a child with unusual movements. If the child if the parent can take a video of them the next time it happens to show you it is hugely hugely helpful tics unusual. Brief asymmetrical movements can sometimes cause parents concern. Is it a form of focal epilepsy? But if one sees the movements, then one can usually discern that they are ticks rather than focal seizures. Focal seizures are usually, um, uh, they usually, uh, the same sort of seizure, which occurs each time. The next form of non epileptic seizure is self gratification in toddler's. What that means is it's a child in a a car seat or in a highchair having a meal, and all of a sudden they start to stare. They can go red in the face, and the reason for this they are presumably getting some sort of pleasure from genital self stimulation. This is a problem of under two year olds. As I said in a car seat. Oh, in a high chair and even with a nappy in, they are perhaps going up and down, still stimulating their genital area, causing them to appear to go vacant and to perspire the red in the face. If you try to distract them from it, they can become quite annoyed, but they will stop doing it. They will be, will come around the difficulty. This it happens more in little girls and little boys. And the difficulty is convincing the mother that this is not a sexual activity. It is not, and I don't want you to ever. If you're talking to such a parent, use the word that it's a form of masturbation. It is not. It is not a sexual activity, because that does not help in the explanation of this activity. To parents pseudo seizures, seizures, which are usually, um, if one videos them, I would actually be confident that any of you in seeing a child putting on a seizure would know that it is not a real seizure. The reason for this is that a convulsive seizure, certainly to begin with, starts with a shake that goes on three cycles per seconds or three times a second. If you think about the heart, there is a default rate for the heart of around 40 beats to the minute and an in adult. And if you get complete heart block, your heart still keeps beating at 40 beats to the minute. Well, the default rate from the brain is three cycles per second. Three hurts. If you try to shake three times a second for 15 20 seconds, you'll find how difficult it is. If you see a an actor trying to imitate someone having a seizure, it isn't easy. Sometimes I've seen Children who have collapsed in school having a pseudo seizure. How did I know it was a pseudo seizure? Because video cameras in the school captured the event, it was put onto a DVD and sent to me, and the child lying on the floor started opening their eyes, looking to see if anybody else was watching. So there are many different ways in which pseudoseizures can be assessed, but it's usually going to be by an expert, pediatric epileptologist, uh, rather than person on the front line. Pseudoseizures often occur in teenagers rather than smaller Children. And should they occur? One of the unfortunate associations is that some will be doing it as to get out of something. And if getting out of something is unwanted, Um uh, sexual activity from, for example, a step parent. One must always be aware of the of the circumstances in which these pseudo seizures occur. Concussion head injury can result in a subsequent seizure. I've already mentioned hypoglycemia, hyper calcium A, um, hyponatremia, and clearly, meningitis or encephalitis can cause non epileptic seizures. When I was talking about fibrinous seizures, I should have mentioned that most of them are simple. Generalized tonic clonic seizures lasting less than 10 minutes with no recurrence within 24 hours. Complex for, uh, food paraseizures tend to be focal last for more than 10 minutes, and they can have more than two within 24 hours. Why differentiate them? Because complex, uh, free brand seizures are more likely to recur in the future, and they are slightly more likely to actually develop into epilepsy later on in life. So in taking a history, it's important to differentiate between simple and complex, free rile seizures. We've got enough time to do a very important short presentation on fits and fence. This is a sort of a referral letter that might come from a G. P. 14 year old boy collapsed at school and wet himself. His parents were called that took him home. His father has epilepsy and he takes so to evaporate. Will you please see him soon? Why? Because his parents are very frightened and we try to see Children who have had a seizure as soon as possible to be able to identify what the problem is, Please see him soon and advise on his management as Philip and his parents are very anxious. Understandably so. What is needed from the consultation to get an accurately established diagnosis and the answer is history. We want to know what happened, Where. How long did it go on for what was the recovery and the people who can offer that maybe the parent in this situation, it's the teacher. And yes, the teacher probably hasn't come with them to to the outpatient department or to A and E. But they can be contacted and information taken from them that is important and last, but certainly not least, the person himself. Philip himself needs to be asked. What did you feel? What it did seem like the history from Philip. He was sitting at his desk in a in a biology lesson. He felt dizzy. He felt lightheaded. A black curtain seemed to come down. You can't remember anything else. The next thing you need, who's lying on the floor slowly waking up. And he had a headache afterwards. So if you were to look at this and say, Well, what features are epileptic? Well, he lost consciousness. What features Favorite being a faint Well, he felt dizzy. A black curtain seemed to come down. Certainly site and vision can be affected in a faint sight. As you said, typically, a black curtain loss of vision, a black curtain coming down with with with, with hearing Children will often you. Often teenagers will say that somebody was speaking when this happened, and their voices became very echoey and distant. So hearing and sight can be affected during as a faint happens, Compare and contrast with epilepsy, which usually most likely doesn't happen with an aura, does not happen with a warning suddenly happens without warning without black curtains coming down or people's voices seeming distant. Headache is very nonspecific and doesn't help in defining whether or not this is epileptic or not. Feedback from the teacher, he contact them. And he said, Could you offer a report on this? Philip was in a biology lesson. He looked very pale. His eyes rolled back. He fell to the floor. He jerked his arms and legs several times. He wet himself unconscious for 2 to 3 minutes, came around around over 10 minutes. By the time his parents arrived, he was able to walk home. The teacher says that we've been try trained in first aid, and they were sure it was a fit. What features Favourite favourite. Being epilepsy? Well, he lost consciousness, he jerked. If he hadn't jerked, then maybe you wouldn't be seeing them in outpatients. What features favorite being affect? Well, he looked very pale. That's typical that they go pale. Then, in this sequence, his eyes rolled back. Then he fell to the floor. Being incontinent is not necessarily a good feature to define epilepsy and a faint. What is important is that he came round over 10 minutes. If you consider that first definition I gave you where an epileptic seizure is one where the brain starts having abnormal, excessive or hyper synchronous neuronal activity, it's not surprising that in most people who have had a an epileptic seizure, they have a post surgical sleep. They feel that you know that that they're devastated. Their brain is devastated by having this, uh, this excess of neuronal activity. So to come around after 10 minutes and when by the time his parents came half an hour later to be able to walk home strongly suggest that this was more likely to be a faint. So the teacher was right. It was a seizure, but it's looking increasingly like this was a non epileptic event, the mother says. Never done this before. By the time I got to school, he's almost back to normal. Perhaps a bit pale and quiet tried to make him have a quiet afternoon when I took him home, but he wanted about to play football with his friends. He gets extra help into school for languages and mathematics, and his father has epilepsy. The features that favor epilepsy is a family history. The feature that favors epilepsy is that he has learning difficulties. But not all Children with epilepsy have got learning difficulties. And not all Children with learning difficulties have epilepsy, I said. It follows from what I said previously. He went pale and a bit quiet when he was seen by his mom. And yet, despite all of this and his mom trying to give him a quiet afternoon, he went out to play football. If he'd had an epileptic seizure, he wouldn't have. He wouldn't have been keen on going out. He'd probably been sleeping for the afternoon and wouldn't have been up to going out to playing football. Examination. Normal normal neurological examination. No big drop in his BP when between an outlying understanding. So it's that that's all normal. What investigations are needed at this point. With this history, I think you will have seen there is every feature that suggests that this was a faint and very little if any evidence that this was epilepsy. Now perhaps it's it's easy for an experienced clinician to make this decision, but I can assure you that in this situation, doing a brain scan an E e g would not be needed. Why a brain scan, even in a generalized fit, is not helpful. And then e g could throw up a minor abnormality, which is not relevant. So you wouldn't want to do any e g in case you get a minor abnormality, which in itself will cause parents to question whether or not they need a brain scan. Well, you do need to do is an E. C G, and you're looking for the Q T interval to be less than no 0.5 seconds. The Q T interval is important to measure because if it's prolonged, it's associated with ventricular tachycardia. So what feature should make you concerned regarding a possible cardiac cause? Syncope associate With exercise Running around shouldn't make you faint syncope with with a fright or extreme emotional distress syncope whilst lying down. You don't normally have fence when you're lying down in bed. Very importantly, a family history of sudden death and a young person under 30 and any sort of atypical history for a syncopal event or an epileptic seizure. So think cardiac in your differential diagnosis this. Please observe. There's some of these, um, young adults who will have a few jerks. They have had a faint induced. This is this is the best one you can imagine. If a teacher saw that, they would think this person has had an epileptic event. But these were medical students who? Hyper ventilators. Um uh, someone pressed on the side of the neck. They did a valsalva manoeuvre. They forced air, tried to force air out with their mouth closed, and they they self induced a faint. So none of the people who have just seen had a seizure. These were all people who were demonstrating normal, healthy adults having a faint with as an associated non epileptic seizure. So as far as fits and fence are concerned, it can be usually distinguished by circumstances and initial symptoms. Stiffening jerking union continence Injury can be nonspecific, so it's not good to use those factors to differentiate. E e g is not needed for, uh, the diagnosis defense. But it is important to do an e. C G. And those are the things which would would cause you concern fends with exertion or sleep or with a family history of sudden death. So I can see there are quite a few things in the chat so that they have a look Unless anybody can summarize what? Here we are. There are No There are no outright questions in the chat that have just been comments throughout. In response to questions that you've asked. So right, one has any questions. Now that you'd like to post in the chat, now is your chance. Is that okay? There's no one asking questions. So, um, someone's asking. Could you tell the three cycle slash second? That isn't a question. Yeah, I'm not really sure what they're asking. Um, could you elaborate on that? What I mean by that is that the brain discharges electricity in a seizure at about three cycles per second. And in absence, epilepsy, it's actually characteristic. What I was saying is because the inherent rhythm of the brain is to discharge at three cycles per second in a seizure. Fits generally occur at that sort of frequency, and therefore, doing having a Sudanese which are putting on a fit is not easy as I explain. Thank you. Um, there's another question. Could you explain how to define the real psychiatric disorder from epileptic epileptic symptom? If you're talking about, um Pseudoseizures the way to differentiate them is by, um, the circumstances in which they occur and taking a detailed psych, you know, sort of social history and psychiatric history, the easy thing that that is the difficult thing. The easy thing was for me as a pediatrician of expertise in epilepsy, being able to know, looking at a child, whether or not a child, whether it looked like a real seizure. And that's when videos become so useful. So having seizures which occur and in response to something is very unusual. Usually they happen spontaneously. But when you actually see the seizure, it just doesn't look right. For example, if if if someone is jerking once per second, that is unusual, that is not likely to be a seizure. So it does depend on experience of looking at people who are having a real seizure. But I would be pretty sure that if you looked up on YouTube and you found a pseudo seizure, very likely you'd be able to say, Well, that doesn't look like anything like, uh, an an organic event. So it is very hard to define. And yet when I'm teaching about epilepsy to qualify doctors, admittedly but but others as well. Junior doctors, nurses. When I'm talking to them, one of the parts of the things that I would teach them as part of the British pediatric neurology associations, Pediatric epilepsy course, I would say, Have a look at this person. Is this a real fit? And I show them a child having a really convulsive seizures and they're absolutely convinced. And then I show them somebody having a pseudo seizure and they say, Well, that doesn't look right. There's something about it that tells you that it's not a real seizure. So its its appearance, uh, particularly the sorceress exception. The flashing light response in a child having juvenile myoclonic, epilepsy or juvenile absence. Epilepsy is due to the brands response to you know that that that many, uh, Children, uh or rather, when when there's a television program or a film being shown and it's and it comes on the warning saying, there are flashing lights. This could affect somebody with epilepsy photosensitive epilepsy. So it's clear that the brain is responsive in some cases to strive a scopic light. What this is saying is that in absent in chartered absence epilepsy, you have no response in childhood absence. And, uh, in juvenile absence and juvenile myoclonic epilepsy stroke a scopic light may not actually provoke a seizure, but with an e e g being taken simultaneously, some abnormal discharges are seen showing photosensitivity. So photosensitivity is the thing that differentiates them from childhood absence. Epilepsy. Thank you very much, Doctor. Unfortunately, we have another lecture starting in a minute, but thank you very much. OK, Thank you very much indeed. Thank you. Thank you.