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This meeting is being recorded. Oh, sorry and just sorry, just before you start, just to remind everyone again, um, please complete the feedback form when I post in the chat towards the end of the lecture and the certificate will be post in the chat. Um, right at the end. So please download it from the chat and if you can't access it from the chat, um, just keep a note of it and hopefully we'll sort out that issue by the end of the term. Um, and I'll hand it over to your doctor. Sorry, that's great. Thank you. Nice to meet you all. Although sorry about the circumstances that have made it necessary. Uh Does anything anybody know how to make myself forced? No. Okay. You'll just have to. Sorry doctor you went. We'll also do a second. Yeah, I need uh I'd like to be full screen. I don't use power points. You will be if, if people have you as a speak of you. Okay. That's great. Okay, so nice to meet you all. Um, as I said, some of you may have, uh there we go. Some of you may um, may already have been two electoral session given by me. I don't use Power points. It's much more about chatting through what's going on and helping you to put together ideas. Yeah, anybody can read a text book. So, so this is just a slightly different approach and, and perhaps a bit of a break from the, from the the norm. Okay. So um last time I talked about epilepsy, I just did one session. I felt that it was quite rushed and there were lots of other things that we could usefully talk about. And so I've asked for two sessions and the second session is later this week, what you have access to is a worksheet because I thought also this is a good point at which to introduce you to the idea of mind mapping if you're not already familiar with it. So, what I've done is I've just given you the barest skeleton and I've got a copy here where I've filled stuff in. Yeah. And um so just something for you to experiment a little bit with. And perhaps even if you decide not to use it, um a bit of a diet to the sorts of topics and the sorts of areas that you need to cover as uh medical undergraduates. Okay? And at the end of the second session or make sure that that this suggested completion is made available to you. Okay, Sun, I'm hoping that we're going to get a bit of a chat going and like most of my sessions, we're going to start with the clinical scenario. You are the junior doctor covering the wards overnight, three o'clock in the morning, it's always three o'clock in the morning. When things go horribly wrong, you're halfway through your shift, you're tired, you need a break, you need something to eat and you get fast bleeped by one of the nurses to tell you that they've got a patient on the ward who is having an epileptic fit, which is not resolving. So the patient has been having an epileptic fit for more than five minutes. This is referred to as status epilepticus, which you'll see on the bottom right hand corner of your sheet. Okay. So you're the doctor on call, you're going to have to go and deal with it. This is a medical emergency. There are two things, possibly three but two deaf in its that you want to ask the nurse to do while you're on your way to the ward. Anybody like to suggest what these might be. Do. Shoutout, join in. Uh You'd have to check the down of patient's whether they might invite it or oh, form on their own warm it. Yeah, I would call a cardiac arrest team because you have to maintain an arrow. Don't aspirate in their own warm. Okay. Well, you don't know whether or not you need an airway yet. Do you? You have to, you haven't got to the ward but there's a couple of things that you can ask the nurse to do while you're on the way. Good oxygen. Oh, good, well done high flow oxygen. One of the very few occasions where you don't bother about the patient saturations, you tell the nurse get them on high flow oxygen, open that valve wide and we talk about why we do that in a minute. What's the other thing that is quick and easy is a common cause of seizures. Uh check blood sugar, blood sugar, blood sugar. Yeah. Okay. So you get there and the patient is still seizing. So the first thing you want to do, let's get a little bit more history is this patient. Unknown, epileptic is the first thing you want to know. And the nurse tells, you know, patient does have a brain tumor and she may have had a sentinel um episode earlier in the day, but it was only witnessed by another patient and they weren't able to give a very clear description and that seems to have self resolved in, in under a couple of minutes. Certainly, by the time the nurse got there, the patient was looking a bit confused but was clearly not having a seizure. Does that change anything about what you're going to do? There are no trick questions. If I ask you a trick question, I will tell you. It's a trick question. Okay. Have to go because one of these days it's going to be you in the middle of the night. Yes, because he's known to have brain tumor. That means he's his ICP maybe raising, you know, the brain tumor is the reason of seizure. Yeah. Okay. So, so it may well be this poor patient that brain tumor has, has now become a space occupying lesion and, and they're, they're now having a seizure. Well, we'll have a look and we'll have a bit to think about common causes of seizures in a bit at this point for this patient. What are you going to do? She's still seizing. She's not responding. It's a grand mal seizure. So tonic clonic, you've got oxygen on blood sugar has come back as normal. What's the next thing you're gonna ask for or do? It's like those hideous exam questions, isn't it? It's like, well, what are you going to do? Well, I'm going to do all of them. Do you get an IV access maybe? Yep. Get some IV access. And who was that? Somebody else? And the elliptical drug diets upon you, diazePAM, right? So you want access and you're gonna use diazePAM, you're going to use any benzodiazepine that the ward has on hand. Okay. DiazePAM IV is a very common world. Most warts will, will have it. Okay. So how much you're gonna give? It's pretty average looks, looking female probably weighs a little bit over. Gonna get, we've got diazePAM, we've got access, 10 to 20 mg. Mhm. You're quite right. No idea. Okay. There isn't a magic number. So, what you need is a nurse with a loaded syringe to start giving 5 mg unless the patient is already using diazePAM for other reasons. In which case, it's their usual dose plus a bit more. Okay. I know. It sounds really vague but this is, it's something to think about because this is one of the medical emergencies where there's sort of a pattern to what you have to do. But unlike a systemic infection, for example, where there's a fixed dose of antibiotic this time, you're going to have to use your own judgment and you're going to stand over that patient while a nurse of ministers, 5 mg of diazePAM IV. And then you're gonna wait. How long are you gonna wait? And then the seizure stops? Yeah, I suppose. How long do you wait until you decide whether or not the patient needs more diazePAM? And second the class itty of the myoclonic like the arms are more stiff. Uh hmm How have about how you say you've given five migs and I can tell you five migs is not going to touch the sides. Five mixes is, is a start point, but it's not going to be enough. Would you wait for another five minutes to see if the patient reach postictal otherwise give another dose? Um I wouldn't. Uh And I, and I have this is actually a case that when I was a junior doctor. I, I was indeed asked to come and sort out. Um, I've only been qualified about 2.5 months. Um, so it was absolutely terrifying. The answer is best guess. So, what I would do is you have a nurse who's administering the, the, um, diazePAM, you have a nurse who is recording how much he's administered a network time. Okay, because you do need to know how much you've given when you're writing up your notes later. And so what I would do is I would and what I did was very gently, just, just place your hand somewhere fairly central and you'll feel the muscles twitching under your hands. So it's not as obvious as the tonic clonic, but you'll be able to feel that don't press too hard and you'll feel those muscles twitching and when you, so if it's not settling yours for another five mix of diazePAM and give it 30 seconds. IV diazePAM works very, very rapidly, okay. And gradually as you increase the dose, you, you will feel those muscles stopping twitching, but they may go on twitching for a long time after the patient is no longer doing the obvious limb movements. And you do want to fully resolve the, the seizure, okay. You keep a note of how much you've given because there's always a risk that you give too much and you stop the patient breathing. But if you know how much you've given you, you know what you have to do to reverse it. Yeah. And in, in the meantime, I would have asked a nurse to um contact the crash team or the ICU Acute Review team, whatever it is you have in your institution and that will depend on how big the hospital is. Um, so I have worked in hospitals where there isn't an ICU and there isn't an emergency crash team um that I was in a university hospital and we had plenty of facilities there. Okay. So what's a psychiatrist doing? Talking about seizures and epilepsy? Why haven't you got a neurologist doing this session? That's not because I have a particular interest in epilepsy. Maybe because of maybe patient with psychiatric um problems. Um because of the medication they are on at risk of revenue future because stressful be induced, stress induced. I don't know what the stress induces. Yeah, it's enormously stressful. There is a relationship between risk of having a seizure and risk of any of depression, anxiety and psychosis and it's bidirectional. So if you are depressed or anxious or psychotic, you are at increased risk of a seizure above standard population risk. And if you have seizures, you are at increased risk of developing depression, anxiety or psychosis. The other thing is that quite a lot of drugs routinely used in psychiatry, alter seizure threshold. And so you have to be very aware of that. And also some people with seizures as part of their seizure pattern, have significant psychiatric, um, elements to it and we'll talk more about that and it's kind of partly why I've asked for two sessions so that we've got plenty of time to talk about all this stuff. Okay. So let's go right back to the beginning. First question to ask yourself is what is a seizure? Somebody feeling brave. You can type it if you prefer not to come on line and, and speak uncontrol. Um, nerves activity. Yeah. Uncontrolled electrical activity in the brain. Brain is an electrical machine and if it's not tightly controlled then it causes problems with your muscles can cause other problems as well. So what it is he's pretty straight forward. Does having a seizure necessarily mean that you have epilepsy. Mm. More aggressive. No, epilepsy is a chronic decision. Sorry, I didn't hear that. Philip Caesar's chronic disease. Yeah. Yeah. So you might have epilepsy. In which case you are massively increased risk of having seizures. But most people who have a seizure only ever have one and no causes ever identified. Yeah. So what, what's that like? Do you think you have, you're out shopping? You're in the supermarket or wherever it is you do your shopping and you come around, you're on the floor, you're lying in a pool of urine, you're confused. You don't remember how you got there. What you recognize that you're at the shop, but you don't remember going there. What is that? Experience like when someone says to you. Well, yeah, you had a seizure. We have no idea why you probably won't have another one but you might have another one. We don't know. How is that going to feel? To the patient? Scared, scared. Yeah. Really, really skinny and, and humiliated. Yeah. People having a grand mal seizure often will void um urine may even void there. Bells. They may have amnesia. Reading uh about what happened. How, how did I end up here? And human beings being human beings here you are lying on the floor in a pool of your own new. You're in no idea how you got there and a load of people staring at you and then somebody says to you, well, you might have another one or you might not and we don't know why you had that one. We're not going to investigate further unless you have another seizure. We don't know. Very demoralizing. Yeah, it's really demoralizing, isn't it? You know what about if you've got a job and you have that first seizure in the office in front of all your colleagues? Sorry, doctor, I think you've been muted. So this is part of the relationship and anxiety. We don't know what the relation act have. I been muted. It doesn't say I muted. You hear me? Sorry, sorry. Um So as I say, most patient's, we have no idea what's caused their seizure. So that's really horrible. However, even though it might not happen again. This is a major life changing event. So certainly in Britain, if you have a seizure, whether the cause is identified or not, you're not allowed to drive for a minimum of a year. You are advised not to have a bath with your bathroom, door locked, not to have a bath. If there's no one else in the house, in case you have a seizure in the bath, if you've got a baby, you're advised that you shouldn't be holding your baby without someone else there and you should never have sold charge of your baby. So the seizure is massive, massive life impact even if you just have the one. Okay. So let's move on a little bit because you're going to do a bit more work. I don't see why I should do the work. Um If you've got your magic thingy over here a green bit. Um It's about causes of seizures. Now, I've come up with 123456789, 10, 11, 12, common causes of seizures. Sun, what's the biggest risk factor for having a seizure? This is a trick question which having had a seizure. Yeah, once you have that first seizure, the risk of having subsequent seizures is greatly increased over the general population. Okay. Even though as I say for most people, it's a single seizure and we never really know what's happened. But for about 40% of people, we have a fairly good idea. So, epilepsy, obvious potential cause of having a seizure. Yeah. How about other things that might cause a seizure? Uh As I say, I've got 12 on my list. So you've got 11 left stress and news and drug abuse. Drug induced. Yeah. What kinds of drugs? Drugs, prescription drugs or non prescription drugs? Okay. Not a solution. Sorry, I didn't hear that. Uh nonprescription. Anybody want to vote for prescription drugs? I think he's both, both, both. Yep. So both prescription and nonprescription. Remember I said psychiatric drugs in particular screwing with the brain and we ought to seizure threshold. We also seizure threshold for everybody who takes them. Not, not just for people with, with a known epilepsy or known previous seizure history. Okay. So drugs definitely good. Well done someone suggest something else for bread conversions, fever, fever. That's right. Pyrexia. All people with the temperature or is there particular groups of people with high temperatures, young Children, young Children are at particular risk. Why is that? They, I put a long, it's not a and went to look to handle a shot of a sudden change in jail. Yeah, small, small Children are little survival machines. If you think about what a small person goes through, they have an in credible capacity for recovery the problem. But you seek physics. They have um it's to do with surface area to mass and temperature control. So they have less effective temperature control. And so they're temperature, their, their internal temperature can get very high. Indeed, adults also can have seizures uh as simply for pyrexia. But it's mostly small Children. Okay. So good pyrexia, electrolyte imbalance. What was that electrolyte imbalance? Yes. Particular one in particular sodium sodium. Why do the psychiatrist worry about sodium? Uh because of the information to the central demylination. Um No, it's because some of our drugs SSRI s for example, particularly in the elderly population can cause falling sodium levels. And so we can give our patient's a seizure vehicles. We've given them a drug that that combined with some perhaps unidentified kidney problem has pushed their sodium down too low. So yeah, sodium, there's another one not an electrolyte that we already talked about the sugar out of the incident, consider induce glucose glucose. Sorry, I'm I'm right by a railway track and there's a huge skip. Laurie outside, moving skips around. So if I keep asking you to repeat things, it's because I've got a lot of noise at this. I said a glucose or insulin induced glucose. Yeah. Why, why does insulin induce a seizure? Sure. But maybe because because uh there's no sugar in the blood blood pathway and it's all taken up because it's the oncotic oncotic pressure. This palace in a sudden, suddenly, suddenly mm yeah, basically give someone insulin. The purpose of giving insulin is to reduce the levels of circulating glucose. If you overdose them with insulin, they become the voices hypoglycemic and are very high risk of seizure. Yeah. So, so yeah, glucose. Um before when people started to realize that for some people with treatment resistant depression, having a seizure seemed to, to reset that and help for quite a long time. Um they used high doses of insulin to drop the glucose level down enough that that they would induce a seizure. So that has actually been used as a medical technique. Yeah. You know about E C T. Yeah, electroconvulsive therapy. Same thing, forcing a seizure. And for some people, although it sounds horrific for some people, that is a life saving treatment. But again, we can talk about that more. I don't know the point. So we're doing quite well. Yeah. Anything. Any other ideas? Stress and use stress induced. Yeah. Remember you increase your risk of over seizure if you're depressed or anxious. So, yes, stress, brain pathology like brain tumour, good brain tumor. What other brain pathology might cause a change in intracranial pressure. Hi, doctor fellas communicating noncommunicating Heracles. Justice men enjoy too. So that's an infection. So an infection of the meninges, encapsulitis, an encephalitis, an infection of the brain itself. And that includes the spongiform encephalopathies which before we realized what was going on often um status epilepticus was it was the first indication that that someone had the bovine spongiform in Kevin. Uh what was that medical disease? Mad cow disease? You have both under spongiform encapsulitis B S E. OK. Autoimmune, autoimmune disease, like multiple sclerosis and Yeah. Yeah. So anything that causes inflammation in the brain, the thing that causes a change in configuration in the brain. So obviously, demonisation would be a big watering electrical activity. Uh But what if triggers uh some people have triggered by height. Somebody I light somebody sound yes. Like what, what what category we put trigger epilepsy or I don't know just so you don't have to have epilepsy. You have a seizure initiated by any flashing lights. Um And one, I would actually exclude epilepsy, flashing lights. Somebody said, could you, could you repeat it again because your voice was cut off? Uh Sorry. Um So, or if you can identify a cause of a single seizure, the chances are that it's not epilepsy. The chances are that it's one of these lifestyle factors, but it could be the first indication that somebody actually has epilepsy. So, so it's a bit of a, a circular thing. Yeah, you're more likely to have a seizure and indeed may well have had seizures that you didn't realize because they happened when you were asleep. Okay. We mentioned flashing lights. If you're doing an E G an electroencephalogram, there are two common things that they do to try to induce a seizure or at least to induce a seizure like activity in your brain. Flashing lights is one, does anybody know what the other one is? You might not hyperventilate IZATION. So if you've got a kitty, for example, you don't say um take some nice deep breaths for me, you get something like, you know, one of these little windmills. So if you blow, uh and so you get the kids to make the windmill go round and things like that and that's sometimes enough to, to cause um seizure like activity in the brain that you can actually record. So flashing lights, hyperventilation, there was a very well known German study on which was initially was intended to be about the effects of hyperventilation in anxiety and panic attacks. And they discovered quite by chance, please do not try this at home that if you hyperventilate for a few minutes and then switch immediately from hyperventilation to holding your breath, you have an epileptic seizure, an epileptiform activity. Um about 95% it was students with their, with their target group. And about 95% of the students who did that had a grand mal seizure, which is quite interesting. So the other thing that can cause a seizure um is head trauma. A friend of mine was doing herbs and guinea rotation. Her first patient was an absolutely terrified 13 year old. Her second patient was an adult, but the partner fainted hit their head on the drip stand and had a grand mal seizure. At which point she decided horse and guiding wasn't for her. So yeah, as, as some blow to the head under some circumstances could also cause seizure activity but would not necessarily the lead to a diagnosis of epilepsy. What about alcohol? Anybody mentioned alcohol? Yeah, if you would, if you're an alcoholic who for whatever reason, just stop drinking alcohol, what's the risk? Okay. What you worry about a medic withdrawal symptoms? And what do these withdrawal symptoms include anxiety, uh Restlessness. The clue is in the lecture title, Delirium Tremens. And yeah, they get seizures, seizures. They also they get the DTs and so on. But yes, alcohol either intoxication or withdrawal increases risk of seizure withdrawal. The risk is significant as many as one in three, we'll have a seizure if you don't treat them. What's the treatment? No trick questions. How did we treat upper listening status? Yeah. Benzodiazepine. Yeah, we tend to use for, for alcohol withdrawal. We tend to, to use chlordiazePOXIDE because it's less addictive than diazePAM and you are working with somebody who already has an addictive personality. Um But again, you'll use whatever you've got to hand, you have to be a bit pragmatic about it sometimes. So why do we worry about people having seizures? What's the big deal you come around? You get on with life, you probably never have another one. If you've got epilepsy will give you um anti epileptic medication, reduce the frequency, hopefully stop completely your seizures. So why, why, why do we bother about people having seizures? It's a lifelong burden. Listen, it, it's a quality of life quality of life can happen again unexpectedly anytime. Yeah. Yeah. Seizures kill every year in the UK that we know of uh usually 6 to 8 people will die in the course of a seizure that is being actively treated. Okay. And there's something called Sudip S U D E P. Sudden unexplained death in epilepsy, which is um usually it happens during the night, somebody's had a seizure during the night and they just don't, don't wake up, they're dead and they reckon that about one in 1000 epileptics per year in the UK is a victim of sued up. This is not just a life altering diagnosis, this is a potentially fatal diagnosis. This is a life shortening diagnosis. Okay. And so get some because you know, it's bad. Yeah. And so if you've got somebody who is then looking on the internet and thinking, trying to fit what they've experienced in and then they discover that one in 1000 people with epilepsy are going to die unexpectedly. That one starts to look pretty big, doesn't it? Yeah. Somebody told you you had a one in 1000 chance of dying 2023. Yeah. And so again, that brings us around to the depression, the anxiety and so on. So it's like a, it's like a circle. Yeah. One thing leads to another and yeah, and that's, that's why I like the mind mapping because it helps you to make these links. Yeah. You know, textbook is very two dimensional because you a list, you know, you can look up that, that list of what's going on anywhere but talking through it. You know, glucose. Why does insulin give you a seizure? Well, it's because it's taken off your glucose. Yes. So you start to see relationships for me. So death, death is the biggie always. Yeah, if a patient is dead, there's nothing else you can do for them. So mostly we try to keep our patient's alive. What, what are the other risks that go along with having seizures? It depends on where exactly you're having decision. You know, it is in a hospital environment, you're lucky you will have full attention. But if you're isolated somewhere and yeah, you won't be found. And if you collapse with no warning in an office, are there any kind of risks with, with that? Well, you can hit your head uh in a table corner in, yeah, get rain, falling something. If you're in the street, I have seen people getting seizures while skydiving. Really? It's on, it's on the internet, a person who was skydiving. He acknowledged that the person is having a seizure in the air and he took him and he pulled out his parachute and he went out. Wow. See, this is where I like talking. I didn't know that I've never come across that. It is much jollier than just reading out a textbook. I hope okay. So you could hurt, you could physically injure yourself. So if you've got a job handle in heavy machinery, handling, heavy machinery, you could hurt yourself. You could hurt other people. Yeah, we've already talked a little bit. It has quite a profound effect on mental health. It interacts with mental health. Remember, bidirectional. So you have a seizure. Nobody knows why you recover from it apparently. But now you're anxious because you're waiting to see what happens if you have another one. What does anxiety do? It increases your risk of having a seizure? Our correctional hazard is like just someone said uh heavy machinery. What if the person is in a military? Yeah. Yeah. Yeah. As soon as you have a seizure in some jobs in a work in a job where you have to drive where you have to handle heavy machinery. You're never going to work in the military. Um So profound social impact. Yeah. Remember we talked about if you're a mom with a baby, then you can only cuddle your baby when somebody else is there because think about there you are cuddling your baby. You have a tonic clonic seizure. All your muscles tighten up. What's going to happen to that baby? You can injure the baby. Yeah. Okay. Let's take again a couple of steps back. One of the things that I talked about, one of your priorities, not just in status but for anybody having any kind of seizure is to get high flow oxygen on them. Any offers for wine, they're, they're not d saturating, saturating at 98%. They're a nice healthy pink color. Why are you putting them on as close to 100% oxygen as you can? Because obviously the neuromuscular junction is not a problem. Therefore, they just create muscles. Are you? OK. So we tried to intubate like so that, that space we are trying to push the oxygen as well so that it could get saturated on distributed. It's much more basic than that. Yeah, not everybody with a seizure is going to be intubated. Remember most people, the seizure terminates within a minute, 90 seconds. Okay. But you still put them on maximum flow oxygen if you're somewhere with an oxygen supply, even if they're saturations are 1996 plus percent where normally you would never put somebody on oxygen. Why'd you do that in epilepsy? Because you never know it might happen again and patient can lose the airway. And no, no, you're focusing on the airway. All right, it is not about the airway itself. Maybe we're trying to get as much oxygen to the brain as we can. So we can help it um regulate its activity back, you're getting closer. So let's think about a grand mouth fit. So a tonic clonic fit. What happens in the tonic phase of a fit? What are your muscles doing? Not trick question. It's as easy as it sounds. Is it something to do with the respiratory muscles not working properly? Yes, their muscles. So when you're in the tonic phase, they're fixed and rigid. What's the clonic phase? What's happening in the clonic phase? Relaxed? No, quite. So tonic is like this and then clonic is like that shaking. Yeah. So are your intercostal muscles working normally? No, not even their friends, you know, so you may not be for at least short period. You may not be pushing oxygen around. May not be oxygenating blood. How long can the brain go without oxygen before you start to really worry about brain damage? 4 to 5 minutes, maximum. 72 to 3 minutes, 2 to 3. Think a kind of handy little thing to, to, to have in your mind for all sorts of things is the rule of three's three minutes without oxygen, three days without water, three weeks without food. Yeah, and that's when we start to have medical concerns about somebody's status. So if we've got somebody who is not breathing properly for 90 seconds, so this is not status. This is a naturally terminating seizure which has lasted between 60 and 90 seconds. Are we worried about brain damage? This is a trick question. Almost 50 50 chance of being right? Uh We've opened shop. I know uh but the chances are if the middle of microphones, you still? Uh Yes doctor. Hello. Hello. So I cannot hear you. 60 to 90 seconds. Brain damage. Sorry doctor. I was, I was in a cork. I wasn't followed before was, uh, okay. So I just picked your name at random. I don't have a picture of you. I'm sorry that, that I caught you off balance. You, patient has a grand mal seizure which self terminates you haven't needed to, to intervene in under 90 seconds. Are you worried about oxygenation for the brain? Um, 90 seconds. So, that's more a minute. Probably not. Yeah. Has there been any brain damage at all in that time? In one minute? Yeah, I said no. Mhm. I say yes. But shouldn't have priority be brain should be supplied with oxygen. Yeah. Yeah. The brain only has enough oxygen to run itself properly for three minutes. Okay. That's, that's the Yeah. So, so yeah, you won't have immediately noticeable brain damage. But suppose you have epilepsy and even when your epilepsy is controlled, you're having two or three seizures a year, you're going to start to get cumulative damage. Yeah. So you might lose a little bit. The black brain is very plastic. The brain can, can cope with quite big chunks of itself missing. But if people are having repeated seizures, there will be oxidative damage to the brain. Hypo oxygenation is going to be a cause of subtle but present brain damage. They will be losing brain cells. No, and one seizure, as you say, pretty irrelevant. Maybe even two seizures. Yeah. Not that bothered. But lots of people with seizures, we never eradicate them completely and they might just have a, maybe a couple of years. But every time you have a seizure, you're gonna lose a few brain cells. And that's why we put the high flow oxygen on to, to minimize that damage to, to overload the body with, with much more oxygen than it would normally have. So you're buying brain time with that and it is one of the very rare occasions where you deliberately over oxygenate. There's another much more popular occasion when you over oxygenate, stepping sideways a little bit. Anybody know what that is. Anybody have any thoughts about her. Do you repeat now, what was that? Would you repeat the question? Uh There is one other common event much more common than seizures where a doctor will deliberately hyper oxygenating patient. Anybody, any ideas what that might be? Is he in coma? Coma? Note drowning? Mhm Are you caressed? No, I was going to say drowning like seizure while drowning but very very common anesthesia. Yeah. Before you stop the patient breathing so that you can incubate them and manage their airway. Yuhei paroxetine ate them. Most patient's, you don't need that hyper oxygenation. But if the lungs are full of oxygen as opposed to the usual 16 or so percent, then again, you're buying time because it for the anesthetist, if there's any problems managing the airway. Yeah. So that would be the other occasion when you give people much more oxygen in the short term. Because don't forget, oxygen is toxic. Too much of it is not a good thing. Yeah, we've covered a lot of ground today. We've done a lot. I hope you found talking. But I ask you a question. Of course, good friend. If you give too much oxygen, like, in a personal. So, what would be the clinical presentation? Well, the patient, too much oxygen. Yes, they stop breathing. Oh yeah, because you, is that the uh respiratory centers? That's right. Yeah. So, so you you muck up the respiratory centers but if you've got a patient in front of you who is going to die and then that's kind of long term stuff. That is the least of your worries. Um So oh sorry message just popped up about somebody's drug child. Um So, so yeah and and this is why talking and asking questions is a useful thing to do because it helps you to to fit things in. So yeah, normally you have a target percentage saturation, don't you? And normally if somebody's needing oxygen, you're kind of aiming for for kind of 96% plus. Yeah, these two occasions you don't worry about what the blood percentages for oxygen you you are protecting the brain, you're buying extra time for the brain, but you do not leave the patient side while they were maximum flow oxygen. Yeah. Anesthetist is with the patient throughout if you have got a patient having a seizure. Once the seizure has terminated, you stop the oxygen assuming that that their, their oxygen sats in the blood are in normal range for them. Okay. So we've got another session on seizures um on Thursday. And um, so I do hope you'll come along to that and we'll finish talking and then after that session, I will put a suggested completed might map for you to, to have a look at and have a think about. Is that okay for everybody? It's been a long hard day. Thank you for coming. Thank you for joining in. I hope you will have time to come on Thursday and I'll see you there then. All right, I'll give you a few minutes break between now and the final session of the day, which I think is tough one, doesn't it? Protein, urine? Himeji, not um So good luck. All right, I'm going to leave you now. Get yourself to dream, move around a bit if you're going to the next lecture and enjoy what's left of your day if you can? Thank you very much for coming. Thank, thank you, ma'am. Bye. Thank you doctor. Um Just before everyone leaves, please do complete the feedback form and you've got the certificate for this lecture in the chat now as well as a link to event right again. So you can look um sorry, so you can book uh lectures um including the second part of this one he follow up on Thursday. Um So that's all in the chart right now and I will end this meeting in about a minute so we can move onto the next one. Thank you.