Computer generated transcript

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

going. Assume you can see this. And you can all hear me unless someone shops and tells me otherwise. So, as Alex said 20 is Jacob, I'm a neurology. Registrars, um, ST Fives, Um, about halfway through my especially training based on the southwest of England's currently in Plymouth. Um, I am going to do this first session on seizures, which is one of the most common neurological presentations to hospital. I'm going to fix it around the diagnosis and investigation of seizures. Okay, with a little bit on management on then, for those of you who would like, I'm going to do more specifically about epilepsy itself next week. So what is this talking to be about? It's gonna be about the headline. Big important take home message is Okay, so what the seizure is, we're going to talk about how to diagnose a seizure, and basically that's clinically through the history. So it's something that anyone can do, and particularly any junior doctor who's Clark in a patient seen the needy, or in May, you You can absolutely do this and get that patient going down. The right track is a decision Or is it something else that needs a completely different management process, going to talk about the important initial investigations on about the important differential diagnoses and then a bit about the initial management priorities, although that would be a little bit on the situation. And I'm not going to go into too much detail. But I'm happy to take any more questions about it at the end. So this talk is not about epilepsy. That's next week. If you're not put off for this one and you're interested please to come, it's not gonna be out how to interpret any GI because that's not something we do well, it's not something I do is a neurology training. I don't know how to do it, to be perfectly honest, and it's definitely not something you're gonna need to do. A PSA foundation doctor. It's also not gonna be about lists of hundreds and hundreds of anti epileptic drugs that don't worry about, so to start off with, just going to just go on three cases with one MCQ on the meats just to kind of set the scene. So if you would be happy, Teo, if you just get your phone or computers and just go on TV box Stop Gap, which is the kind of online polling, uh, platform, which you may have used before on then just add in that session idea It comes up with a boxing into session idea. If you just put that in and just got a few empty cues that we give, just get kind of spread of what people think initially. And then we're gonna do the bulk of the talk and then repeat the questions afterwards and see if people change their minds. Okay, so the number comes up later if you have the chance to go there. But the box don't because the website so three cases to start with their ulcus is I've been involved with in the last few months really life cases in Plymouth. We as neurology, trainees and urology doctors do that. The stroke services. Well, so we spent quite what time in the CDC in people presenting at the front door with something neurological. The key question really is, you know, Is it a stroke? Don't need to thrombolysis them or or is it something else in there is a singer or what? So you know a big part of what we do is about trying to get that diagnosis right at the start on. It's just a really nice kind of clinical approach, and it's like being a proper doctor, you know? You see someone, you take the history. Do you do the examination of decide what you think's going on? You start the start, the management. So this was one patient I saw a few months ago. He got helicoptered in as a stroke alert. You know, this person has got slurred on D unusual speech. You think he's a phasic? You know, I think you might be having a stroke and might need to be thrombolysis. Getting tossed it as quickly as possible is a 63 year old man who was pretty well, drank a little bit too much alcohol, worked as a caterer and took a few kind of fairly standard medications. Um, when I started out the front door, he had actually got quite a bit better from Harry Waas and over the for a half an hour or so, he basically got back to normal, so I didn't need to worry about kind of from relies in him as a potential stroke because obviously if someone's back to normal, you're definitely not going to throw up ELISA. Um So it quickly became an issue about what happened. Was it a stroke that got better? So ta, or was it something else to be? So he couldn't remember. So speak to his wife over the phone, and this is basically what she told me. She said we were at home. I saw him fall down. He was on the floor. It became quite stiff and clench his jaw. And he was just staring forwards on not responding. So kind of on responses is something you get told quite a loss about patients. He was gonna unresponsive and that she was talking to him and he just wasn't responding and didn't seem to realize that she was there. And it just stayed like that for maybe a minute will say on. Then he started trying to speak out for a few minutes, but was really confused and just not taught himself. Which is when that hey got court, brought in a suppository stroke on. Then by the time I saw him, which was basically about an hour after it started, he was back to normal. So you're fully recovered over about now. So with that, if you just quickly tap in what you think the most likely diagnosis is? You know, it doesn't matter if you're right. Wrong. Just gave you Got feeling. I'm sure you probably will be right to see what kind of spread we get on the the up there for about 10 seconds more. Okay, let's see what we got. Okay, so that means we're going procedure. I guess this is a talk about seizures. So they asked me, Probably quite give that start off with a few people gain for T I a single being a strike. Okay, so case two different situations. Someone I saw in our kind of first fit clinic a few weeks ago. 16 year old girl came in with her mom. Background of anxiety and depression was under the cans teams. The child adolescent mental health team was on search, really studying hairdressing, it a local college. And she described about six weeks of of black out. So again, it's something, you know, here, quite on responsible blackouts. You know, that's something you just need to really pick apart, work out what it is. She's been having these up to five times a day, quite like in a day in, day out for six weeks. Five of thumb I'm a history from her was that she gets a little bit lightheaded and then just feels like zones out. She's not able to do what she wants to dio. I can't record record everything, but she says that you can hear what's going on when this is happening. And then the month says, Well, what I see is it's just kind of shaking her limbs. She's going back. Actually, her eyes are open legs ago, the arms of going the longest one lasted about 15 minutes. That might be a shorter five minutes on. She got back to That's normal pretty quickly after each one, sire. Same question. What's the most likely diagnosis is for this 16 year old girl. Okay, uh, seizure. Think be decisive. Attack. Okay, great. I should say I'm using disassociative Attackers. My kind of favored term for what's also noticed a non epileptic attack or or a pseudo seizure, just in case just to clarify that story with that with the last one. Okay, Good. And then finally, case someone who got admitted to hospitals ends up on the medical assessment units. 35 year old lady. Well, p teacher. No medicines? No. Nothing else. A partner had seen her in bed the night before. Just suddenly become unresponsive. So she actually kind of like she lost consciousness. It was pale. She had jerking of the arms and legs. And this all lasted maybe 30 seconds or certainly less than a minute. And she came around. Not immediately, but pretty quickly. Over five minutes. A Z don't have another event on. That's when they thought you need to get hospital. So I'm giving you all the information. They're slightly different. Question. What do you think? If you had to pick one of these investigations will be the most important. What one would you choose if you could only pick one of these? So I'm thinking in terms of making the diagnosis and also not missing something. Yeah. Not missing something dangerous. Okay, See, we got there. Okay. So, bit of a spread. Their CT has most popular bit of a spread around all the others. Okay, great. So just keep those in mind. We'll come back to one of those end so bit more of me talking. So what is a seizure again? You know, big, simple things to hold in your mind. A seizure is just extra electricity in the brain. Okay, I'm sure you will know this, but it's really important just to hold on to that. I think you know, as you're studying in medical school, I found is you're pretty good at these kind of definitions and kind of, you know, the scope of lots of different kind of medical and surgical conditions as you come out through medical store. And then during your foundation years, you basically spend two years cut for getting this kind of stuff on, just, you know, doing the job. You know, learning how to run a ward, roundhouse have prescribed medicines. And the right dose is etcetera on. Then I personally have kind of spent my year since foundation training kind of re learn all this stuff. So if you can hold onto it, great. But you know, you can always re learn in the future if you need that for a seizure. Just remember, the seizures is extra electricity canes from my my first key point here of the talk radio is that anyone can have a seizure is a kind of a misconception that, you know, seizure equals epileptic. That absolutely is not the case. Okay, there's note of reasons why people can have a seizure, and any normal person can have a seizure. We've all got a seizure threshold, Okay? There's listed a few things there. That's by no means exhaustive. You know, if I finish this talk and drink going, drink to need to live blocker, I'll probably have a seizure. If I inject myself with a lot of insulin and give myself a terrible hypo, probably gonna have a seizure. Okay, um, all these things here can provoke seizures in any normal person. Okay, Yes. People with epilepsy can have unprovoked seizures, so they're obviously more prone to it. And they, of course, can have a seizure for kind of less of a reason. So they might have a seizure anyhow, after having a small amount to drink or having a mild high pain. But anyone could have a seizure on if that someone's have a new seizure. You're ready to think hard about why that might have happened? Because some a lot of those need very specific management's seizures. As I'm sure you know you can. We call the wide a focal onset generalized onset. So if it starts in one part of the brain, it's focal onset. People might not lose the way I understand they might just get a jerky of one game, and then it settles down. We kind of remember all of that. They never kind of become confused or anything, but it can be focal onset that then, but causes kind of reduced awareness. Or it can be generalized onset. And all of those are going to cause kind of, um, easier prevents and usually have a quite prolonged recovery afterwards. That's a very briefly you broadly, you know, seizure. Is it typically brief? Okay, so the brain's got pretty good mechanisms for shutting down seizures. So generally a seizure shoot last more than a few minutes. Of course, you know, some in status. That's a different situation. They got really sick. But the vast majority of seizures don't last any more than that. Maybe a minute or two or three. And most for people who have more than one seizure. So typically people that let's see, they tend to be the same type of event again and again. Exactly. Helpful. Diagnostically know, Beware the patient who comes in and says, Old Doctor, I had another one on my T i A, you know, having one every month. You know, people don't have the same type of tea I again and again. Okay, that's much more likely to be a seizure leading on to that. Just remember that seizures to be give you positive symptoms. You get extra stuff, extra muscle contraction. The extra movements get extra sensations of hallucinations or smells or whatever. Whereas strokes and t A and syncope, you can lose your blood supply to get negatives, intensity and lose power. Your new speech and news fishing. Yeah. And so, with a seizure, you know, you can get I can typical postictal phase, which is really helpful diagnostically but only in generalized onset, where if you have a focal onset with altered awareness. But to be honest, those are those are the ones that come hospitals and most of those you know, most of the seizures going to see in hospital will have some kind of postictal place. Okay, That's all I'm gonna say. About what A seizure is a very basic, Um, how do you diagnosis? Usual second key points. Seizures diagnosed clinically. Okay, there's no test. That kind of confirms the seizure. There's no test that instead of certainly noticed that rules out with seizure on, there's certainly no test that rules out. Epilepsy is basically all just done on the history. Okay, So, you know, as as a junior doctor, this is what you're doing with all patients. Really? Isn't. You're taking history. I think the diagnosis CJ degree is a little bit more efficacy. Little bit more involved. That's because normally patients can't remember exactly what happens. You normally have to go and find someone who saw what happens that you need to get a classroom street from a witness. Okay, Um, Andi, you're taking the history. Just really think about what what happened before what happened during what happened after it is really helpful structure. If someone's got a video, then brilliant. But I always recommend kind of documenting in the notes your assessment of what that video shows. So it's really clear also in the history, you know, I'm not going to tell you everything to ask your history, but obviously, if someone's got known epilepsy who have seizures in the past. That's really helpful to know. Okay, because I want to be more prone to having seizures doesn't mean that whatever they come in with this time is a seizure. But it just changes. You're likely. So you would always want to ask that in your history. So in terms of diagnosing seizure in taking the history So this is, you know, kind of break brief kind of schematic in a table about what's the typical features that happening before, during and after event according to whether it's a seizure. And they're not what I think of the main two differentials, which are syncope. So lack of blood flow to the brain, causing a faint or a dissociated attack or also known as non epileptic attack a little cereal with seizure. Um, you might get a warning with all of them. Okay, syncope. You're thinking about things like that. Lightheadedness know something cardiac like palpitations or chest pain. Okay, seizures and decisive tax bit more variable, but people do get to get a little bit a sense that it's coming up again or in terms of during the timeframe is really helpful. Okay against that's pretty something. People are very good. It necessary documenting. Because if you take a really good history, you explain exactly what happened before, during and after it. You've got a really good sense of how long it lasts, But the person who comes in looks that next actually can't really get that from the notes. So definitely just try and document or work out for a witness was something it lasted seconds or minutes or longer. Okay, that's all it needs to be. Second suggests a syncopal event mawr than five minutes and someone who's not really unwell suggested it's not a kind of generalized seizure where, as we said before, you know a seizure? Um, it's typically just a few minutes again. Kind of, You know, stiffness versus floppiness is really helpful from procedures, extra activities. You get stiff syncope. You fainted. You get floppy, you go pale, so it's just just kind of opposites. But people aren't particularly good at describing unless you particularly get, unless you specifically asked them in terms of differentiating a seizure from a decisive attack that can be can be a bit tricky. They're more commonly someone's eyes closed and the decisive attack and open during a seizure. If someone being blue inside nose as much more suggestive of a seizure lateral tongue bites of really suggested that generalized seizures. Okay, incontinence is not is not that great, because a lot of people believe in constant with syncope. I'm just going back to the tongue bites tend, buy the tip of the tongue is not such a good sign, but a lateral time. My big lateral time by that's very suggestive. Someone's had a compulsive seizure. And then afterwards, you know, after it's really helpful. Sometimes you haven't got a witness for actually what happened during the events on It's more about how how the patient is afterwards, even if you have no idea what happened someone for a minute while they're in the kitchen. But then they came out, and that's staggering around. They confuse and they don't know who their wife is. The don't know where they are, and it takes them two hours to recover. That's really suggestive of a generalized seizure. Okay, where it syncope Indecisive attacks should be pretty quick. Recovery. Okay, So quicks for genetic. About differential diagnoses to hold in mind when you're doing the history. So as we said, seizure syncope, decisive attack. Okay, if from your history you think that this is most innkeeping with a seizure, then I would say the next stage is to think about whether it's have provoked seizure. Okay, So is there anything in the history or their initial investigations to suggest a reason why they've had this seizure on, if know is it an unprovoked seizure? Okay, you're going to go on and think about you know, whether this means they've got epilepsy. But you just you're going to person making that diagnosis normally a specialist diagnosis in terms of our first picked for me. Okay, um, of course, people with epilepsy can have both provoked and unprovoked seizures in terms of syncope. That's a whole separate talking itself. So I won't dwell too much on that. But if you're through your history, you think someone had a single event, you know, don't stop there. I think about why you have my the had it since he is a reflex and could be like a vasovagal. Is it some kind of cardiac out through track obstruction like a a lot explosive missing for the murmur is an arrhythmia, you know? Look at me. See, GI? Is it all the static? You have the gout, postural BP drop Syncope can kind of give you a little bit of drug people faint can get a little bit of jerking. That's often called a kind of a convulsive syncope. That's not true seizure, but but definitely people can have jerking and twitching after a faint. Some people would say that that I think we can actually trigger a generalized seizure that have a little bit more controversial. But I think that probably is the case of some people. So So really, I think people who faint and then go on and have a seizures that provoked by secret be so these things aren't completely neutral. Exclusive. Okay, One thing can lead to another on there. Certainly plenty of people walking around to have plastic seizures on decision attacks. Okay, so these things can coexist, but but you should do your best to try a different sheet. Okay, fine. So sticking with diagnosis. So I I think the history is how you make the diagnosis. The examination is then you're basically looking for anything that might have caused a seizure and also to look for any injuries or any consequences of the seizure. Okay, so big things, you know. Are they unwell? Do they look like they've got sepsis or the federal? And particularly if you got some with new sepsis and of seizure, You thinking about brain infection? Meningitis In careful itis on, that's important to think about because you need to give slightly different antimicrobials. If you give you a general kind of pneumonia or urosepsis type antibiotics, they're not necessarily going to penetrate there. The blood brain barrier. So you were thinking meningitis. You can specific high dose things like kept track soon and for name careful itis, you know, for an effective in Quetta like encapsulitis, that's basically always viral, so you need to get him antiviral. So important to think about that, the back of your mind. We do see lots of elderly people in particular who get septic for other reasons, like pneumonias like you're in. You then have a seizure kind of provoked seizure from sepsis, and they don't have in their meningitis on encapsulitis so that that is quite common. But I think in most cases you don't least cover them with the antibiotic with that kind of meningitis and cath lighters Antimicrobials until you know definitely what What the source is You have to do a form urological exam. I'm afraid, um, really helpful stopping the GCS. You know, someone's really drowsy and, you know, possibly postictal do the chiefs. Yes. And then in a couple of hours days, you can compare it to say, yes, this person's improving in the way I might expect someone to you after a seizure, and they got any focal deficits. So, you know, you know, last for a weakness hemianopia something like that that suggests, you know, a structural brain problem, maybe a stroke, occasional stroke, contribute a seizure, or, more likely, something like a brain Jimmer or another spacer on. Then a few other things on general examinations and lateral tongue bites we talked about, You know, if if the patient can't voluntary, just look for them. Okay, Um, look for injuries. Think about the cardiovascular is other things. Say murmurs like Stanley, BP. Okay, fine. So that's diagnosing seizure history really make the diagnosis collateral examination to think about what might have caused it and any consequences, like injuries. So investigations know got too much on this. He cg sed is basically the only man did tree examination for someone coming in with a suspected seizure. Okay, nice guidelines. Any any adults for the seizure should basically have any CG bloods, including electrolytes and blood sugar. So those are your big three okay on. But I think that probably goes for whether you think it's a syncope or a seizure or a decisive attack. You know, I think all of those things are still still relevant, but if you think it's a seizure, you know you have to do those three on. BCG is meant to be the most important because of the risk of missing something like a cardiac arrhythmia. That's a cause of syncope or because seizures can sometimes cause cardiac arrhythmias as well. Often people end up getting, you know, head imaging, usually a CT that's not always necessary. But you know if there's any kind of concern about a structural brain problem, particularly someone with a new seizure, particularly like an older adult, they normally get except get some brain imaging. You know, someone with with epilepsy, who's who's having seizures, you know, a few times a year. You know, if they come in with a seizure that just been taking it longer to come around and that's why they're in hospital. But then they do fairly recover. That person typically doesn't need doesn't brain imaging? Yeah, Um, just a little bit about EKG. Um so EEG es are really helpful if someone's had one unprovoked seizure and then we typically don't say that's epilepsy. To provoke seizures, toe have a diagnosis of epilepsy or one unprovoked seizure and something that suggests you're at higher risk of having mawr, such as an abnormal EKG or not horrible brain scan. Okay, so if someone has one seizure and abnormal EKG, we typically start them on anti epileptic medicines or least offer that to them. So it's helpful in that situation is also really helpful from a kind of acute admission point to do in terms of someone who's had a seizure on. They're not waking up. So then, in that situation, you really want to know if they're having ongoing seizures, you know, little ongoing seizures, that keeping them drowsy or whether they're just someone who's who takes a long, long time to wake up and that could be really hard to tell clinically on. Obviously, if someone's having ongoing seizures, you need to treat that, and they're going to be much worse if you don't have any. GI is really helpful to little ongoing nonconvulsive seizures in a patient who's kind of persistently drowsy. Any GI can't exclude epilepsy. So plenty of people with that, Let's see walking around to have normally geez on but also thought I would point out that the night guard, I specifically state that you shouldn't do any GI where you think someone's had a syncopal of it. Okay, so again, it'll kind of starts from the history of the history of suggested syncope. Don't do any GI because you could easily get a false positive, and that's just going to monitor the waters. And if someone ends up on anti epileptic lessons, dress their life unnecessarily. You're not doing them any favors of the few other things you know you want to do a general septic scream if they're federal, you know, kind of mentioned that my include a number puncture, because that's basically how you diagnose and meningitis or encephalitis anti convulsive levels, not majorly helpful to be honest, The main reason we use them. A zitfree think someone may not have been taking them medicines, this one with epilepsy, and you're not sure they're taking them on Then if you do a level on their admission bloods and you can't detect any of the anti convulsant, then you kind of know that that's the reason why they kind of seizure. So that's that's where that makes helpful. The other one is when, um, someone's friend. It tones get lonesome without it. So and you want to kind of tweak their ongoing maintenance level. Because from military is kind of metabolized differently by different people, you have to do a level to kind of guide that they are. Two main reasons resented blood levels. So moving onto management is the last section it depend on the situation. I think you know the first kind of the first main priority is to think. Does this person have ongoing seizures? Some was coming with some kind of episode. Um, if they're not fully recovered, is it because they're still seizing? Okay on? You could do that. Like I said, you know, with any GI. But that's not that available if you don't really get that in 5 95 where I work and probably less available in other hospitals around the country. So what you could do is just look really careful. It really is just inspection. Say, if you know that someone started the seizure on kind of one side is for a look at that side. And if there's a little twitch, if you see like a face on an arm twitching at the same time, you know, face and arm, you know, equal somewhere in the brain is the same as a stroke. So if you see a little little twitches, if you see kind of which is the eyelids or repetitive movements of the eyes, that's quite suggested as well on often in that situation, you know, you're gonna need to get support on, get someone get him into a safe place, But you're probably going to need to give him some more medication to see if it see if they wake up. Um, so on going seizures, you know whether the convulsive or nonconvulsive is basically status epilepticus, which is I'm sure you will know, is a medical emergency and basically to manage with an A B C D E. Approach. I'm not going to get into too much detail about this, but I think it is always important to bring this up and talking about seizures. So the key things that you know you could do it immediately is to get the patient into the safe position. Okay, Put auction on high for auction. Check their blood sugar. Um, make sure there's a Procrit people around. Okay, I don't think you would be on your own managing this very often. You know, I think people either come in with the status pre alerted by the ambulance and they go straight to recess. Or typically, what I found, if it happens to someone, is an inpatient with a seizure. But then they generally get kind of a rescue or medical emergency team calls. At least there's kind of a group of people going up. Um, whoever gets the first needs to do those simple things in terms of medications is gonna very little bit according to where you work in terms of local guidelines but basically benzodiazepine, our first line, and in hospital, you typically use IV lorazepam somewhere between 1 to 4 mg a day, one off those, and then you can repeat it again after about five minutes. If they're not, if they're still seizing. Okay, there are other benzodiazepine options, so PR diazepam on buckle midazolam. They're more used in the kind of pre hospital setting an ambulance stuff, but in ambulance settings. But if you don't have access, for example, then they're perfectly reasonable. But normally hospital way use IV lorazepam. Most states is most ongoing. Seizures will will terminate with Benzo's, but there's a kind of a few different second line medications that you're probably come across that I just mentioned briefly, and they're basically key thing. Is that kind of all? Pretty much the same. They're all given IV over about 2030 minutes on there, or equally effective broadly at terminating seizures. Finito in is the one that's historically been around for the longest about breaks, and then we'll recently Levitra Stem or keppra can be used by Just make a quick point about the dose of Levitra acid. Sam is 40 mg per kilogram. Okay, you know, there's a I just say, if you're going to use that for someone who's actively fitting to try and terminated. Make sure you give that full dose case of 40 mg per kilogram in whatever you know, 50 even just a 50 kg person is going to 1000 mg of grounds kind of standard. You know, I'm not quite sure. Let's give someone from Keppra because they have because they got some seizures, which I see quite a lot of someone just getting 1 g. That's not a full load. Okay? So just just be aware of that base. Okay, Um beyond that is anesthetic agents okay on. But that means that the cyst or intensive care So when you're giving a second line medicines, they need to be aware that one is taking some 1 to 10 scale. Assuming that that is the right thing to do for that patients. Yeah. Okay. So, firstly, other, any ongoing seizures, if so, need to be managed emergency in the Procrit supportive setting with enough help around. Do the simple things option, blood sugar positioning and then think about getting getting medications. I one about if it's just someone come in with some kind of event, some kind of loss of conscious of that you take in the history. You think It's a seizure on. Then you won't work. Half it's provoked or unprovoked, which basically is the same thing. You know? Can they go home, go home and have outpatient followup safely? I'm now, I know that you know, you might not be sending people home independently, but I think particularly if you're working in the emergency department, you know, pretty busy you're gonna discuss it with the senior, but they're basically gonna make their decision based on the information you give them. So you have to be really comfortable with yourself. You've taken a program history. You thought about the different things that might provoked seizure on. But you happy they're not there. Okay, so that's gonna be the thing that we discussed the history to decide that. You think it's a seizure, the examination and the obs Think about what might have provoked and your initial investigations. Okay, think about any injuries that might need a dressing. If you've got any suggestion of something, it's provoked it like an infection, like a low sodium Michel. Oh, blood sugar. If someone's withdrawing from alcohol, then that also gonna leave managing in a specific way became that probably going to need to stay in the hospital while we correct that underlying thing. Okay, if, however, there's nothing to suggest a cause of seizure and it's just some things come on after blue and they're fully recovered. Uh, then that person doesn't need to stay in hospital, Okay, but they do need some kind of follow up. So if it's if it's a first fit and then not know whether, let's see, then you need to be referred to the the first fit clinic on that will depend. You know the process that would depend on where you work. Nice guidelines say that suspected first uses should be seen urgently, which they say should basically within two weeks. It is urgent, but it's not super urgent. Okay, if someone's got, let's see and they've had a seizure, but they fully recovered. You know, I think you just need to make the epilepsy team aware on often. The best way to do that is to get in contact with the pellets nurse. You know, either by email or phone, or if you got a neurology registrar around, you can drop them in line. But I think they're regular. Team's gonna want to know if they've had a had a seizure is brought mental hospital. Okay, if somebody's going home, just remember to give them some safety of ice. Okay? Tell them not to drive. Okay, Tell them to avoid heights. Don't go swimming, have a shower, not a bath. And then just to avoid things that would increase the chance of the seizure in anyone, so don't drink, don't go home and have an alcohol binge. You try and get really nice stable sleep on. I think I always say, you know, ideally, you know, have someone around you for the next few days because it is gonna happen. It's probably gonna be in the next few days at the highest risk period. Okay. In terms of driving, I mean, you don't have to tell them the specifics, because if you're referring the monster first fit assessment, that's that's, you know, the final suitors going to be made there. But essentially, they shouldn't drive until they have that specialist assessment. And if they do ask more than that, you know, for a nap for a seizure, it's at least six months. It might be up to 12 months, depending on the results. of the test like the gene things. Okay, so just last couple sides for it. In patients with seizures, you had pretty much everything We've discussed His applies already, but I was just going to make a couple of kind of specific points. You know, if you call to someone on the ward, they've had a medical emergency or nurses. So was that a seizure? You know, one thing, that kind of seizure, But they're okay now. If they've got no nipple, it's easy to think about the medicines. Okay? It's really common for people with epilepsy. He might be on slightly complicated regime to might not be swallowing properly. They run well, except for except for to not be taking those medications appropriately. Okay, on the other things. Antibiotics, you know. So about six things like ciprofloxacin levofloxacin a really notorious for lowering seizure threshold. I might be a reason for For what? You've had a seizure. So you think about changing it to something else. The Procrit. It doesn't have a epilepsy. Need to think about everything we discussed already in terms of all those provoking factors. But but really think about alcohol. Withdraw. Okay. Has someone taking that alcohol history correctly when they got clocked. It's now 48 hours down the line in the having a seizure. You know, that's a real plastic timeframe for having on how call withdrawal. Seizure. Okay, great. Let's put all the bulk of what I wanted to talk about. So you're gonna get out to the case now and see if we change our minds that anyone on any answers and that you know what I think we the right answers are So this is our 63 year old man who's helicopter, then drowsy. And third speech. He got better over an hour, and it had an episode where he fall into the ground and got stiff for about a minute on, then being confused afterwards. So second chance on what this one is, What people think like seizure was the was the top one last time. Okay, Okay, So this person had a seizure. Okay, I know that for sure, because you come in about three times since then with more seizures. Hey, had a normal EEG eeg, actually, but a slight abnormality in his MRI. Just a bit of scarring. That probably is the cause of his seizure. I think in the history Is that our of being confused and disoriented? Yeah, that's a bit too long for a syncopal t I a. I mean again. Yes, he had that kind of speech disturbance that then got better than our That would be the right time frame for a t I. But that history of stiffness and staring really wouldn't be typical. And people tend to not collapse with a t I A Okay. I mean, you might get weak and four, but you don't tend to, like, hit the deck and be vacant. That that would be a bit unusual. Okay. Eso he was a a seizure. So, um, other kind of new diagnosis of epilepsy exact a second of any time. He hasn't put you on top of a few more. Okay, what about are 16 year old girl? The background of anxiety. Depression has been having up to five events today when she gets a bit zoned out and she could still hear what's going on, but but can't respond. Bit of shaking and last between 5 to 15 minutes. Curves. Yeah, so mostly right there. Absolutely. Um I think so. I saw a video. This one, which was really helpful. Mom came in with a video. I think most of the people who have their events film that probably decisive because they go on a bit longer. People bit less worried about them. So, you know, it's not, You know, I'm not going to rely on, but most of the time that this is a super attacks. I think with this that actually could still hear what was going on meant that, you know, she wasn't completely unaware on the really rapid recovery. One of them. She was kind of shaking and driving for 60 minutes, then to just suddenly go back to the normal. That very, very unusual for a generalized seizure. Okay, it's too long for syncope. Okay, You caveat. Course I was seeing you have People are kind of sitting up and they kind of fate. And then people keep them sat up, and so they kind of keep moving. Not enough BP. Your blood profusion going to rain. But if you lie someone down quickly, they recover. So Okay, You think you could go on a bit longer, but But generally it's just seconds on the last ones this like on a Well, ladies had a couple of ENTs over my toe. Pale unresponsive. Is jerking king round in five minutes. So single most important investigation. CT head was far in a way that when a last time. Okay, Okay, good. So no 100%. But we had a big swing. Too easy. Geez, say, I think some people are listening, at least So you know, I think of blood Sugar is important. You definitely would do one. But I think if you had to pick one, you know, it's probably her history of the most in keeping with the syncope. And then she's probably a bit of jerking, you know, as a result of the syncope on. Actually, this lady had a an abnormal EKG with with some kind of heart block comma really vacuum what? It was. But she ended up getting a pacemaker, actually. So she was having syncope due to a rhythm here. So the EKG for her was absolutely key. You know, if if you said you've been normal support, it would have come under neurology and brother. But with that abnormal, he, he suggested, was just 100% with cardiology and got that salt it straight away. Okay, lets me down. Um, five points to take home one. Anyone can have a seizure. Okay, Doesn't have you don't have to have epilepsy seizures diagnosed. Clinically said you can do that. Is all it needs is a detainee now. Careful history from the patient and from a witness. Okay, Don't need any test to diagnose a seizure. Um, I think about seizure most of syncope versus a decisive attack. If you think you know, if you think it's a seizure based on the history, just take it that one step further and think Is it provoked, or is it unprovoked? And that was just slightly change. What you do is just keep it in the hospital or your initial management on the key investigations for kind of any of these are the C G first and foremost blood sugar on greeting bloods with try. It's okay. Thank you very much. That's the QR code for some feedback. Please. If you get a chance to that, we're very grateful. And if you've got any questions, we're going to time. So I'm very happy stick in questions that people have so much Jake a low. So that was fantastic. Really good introduction. Sort of seizure management. Certainly help me. Structure how I sort of go through it in my head. We've got a couple questions on the chat which is done. Fired medal. Feel free to stick it in the child. You Any questions? The first one is so how often wouldn't EEEG be done on a patient. This already got established. Diagnosis off. Epilepsy size, parts of routine management. Okay. Yeah, probably not that often. I would say, You know, if you've got someone who's no nap elected and they're gonna want to be on kind of long term anti epileptic agents on they probably they would have had any GI. I'm sure that kind of time of diagnosis. So probably in that situation, it would be, if you're worried that having ongoing seizures, they says they can not wake up after a seizure. That's probably most likely, you know. Occasionally a psychiatrist suggest alluded to before some people can have epileptic seizures on dissociated attacks, and sometimes we arrange for people to have kind of a long term e g over a few days to try and capture and event on that could be helpful to try and see whether it's an e g corollate. So whether these kind of a new type of event is actually a political, not occasionally if someone just kind of isn't really responding to medications, right, well, it can sometimes be a bit helpful just guiding the anti epileptics we use. I think you know the norm for that will be that people with epilepsy have a seat. You don't need another E J. Right? We've got another question from the audience by, say, Position, gym in the recovery position or anything that works, It's anything that works, really, It's going to depend, you know, if they're really convulsing and kind of, you know, moving a lot that you just want to make sure they're not buy something hard there, they're going to injure themselves. Typically, it means kind of on their side, you know, kind of safe airway may be holding there that actually draw thrust head tilt with the oxygen on. It depends a little bit, you know, in terms of the situation, exactly how they are moving on what they're on at the moment, you know, returns in a bed or a trolley or anything? Um, but yeah, Generally on that side is it's safe. Okay, Um, got a couple more. So what? One that says, Can you be aware during a seizure? All right. Yes, you can be, um you know, see that there are loads of different types of seizures on some of our very odd. Um, I haven't really scratched the surface there. Say never say never in medicine. But, you know, if someone's just having a focal seizure, So I shall someone today, for example, who's having little twitches off her face and arms that came in with a with a seizure. Kind of generalized seizures, ongoing twitches. But she's completely with it, you know? She could talk to you. She can see what's going on. She's not confused at all. She's basically got what we call kind of focal motor status. So she's going focal. Seizures are just causing movement on that. Ongoing safety is the state. But she's completely aware so, yes. If you're just having focal seizures, then you can be aware during them. All right, we've got another one. What is the difference between seizure and convulsion? Are they in the changeable? Um, I mean, Well, I guess a convulsion is a kind of actual kind of movement, isn't it? So you can talk like a convulsive seizures. So I think that more first to the kind of rhythmic movement where a seizure would describe any type of any type of electrical over activity in the brain, which could be, you know, a non compulsive seizure. Like, you know, you know, a NordicTrack loosen a shin or my clothes nurse or something like that. So I think that they probably are used interchangeably, but they're not exactly the same. But in terms of the kind of emergency seizures that you see coming into hospital, you know most of those will be compulsive. Yeah, I sort of got a follow up question that myself. Is there any sort of non tight clonic to do sort of generalized seizures that should make you sort of really worries that urologist, just in terms of sort of potential diagnosis of sort of mostly more dangerous of epilepsies is it works. I mean, it sounds of ongoing seizures. Obviously, compulsive status is that is the most urgent. That's generally what we mean. We kind of stay status. Epilepticus is because with all the kind of electrolyte shifts and everything, they're the ones who are gonna die Quickest. If we don't stop it, and then you've got kind of things like focal motor status. Like what? I was talking out there where you want to try and get on top of it. Stop it getting worse. But actually, it can go on it for quite a long time. And then you've got non convulsive status which normally, people just very flat, they're not convulsing. And again, it's something you want to get on top off pretty quickly, but they typically don't need to go to lie to you and have anesthetic agents. To do that. You normally have time. You know, over sometimes it days, to be honest, to try one medicine and then another hum pretty thank you. I think we've got one more. So it's so the first investigations et gi blood sugar and electrolytes done procedures only, or both seizures on sync. Well, that that was taken from the nice guidelines, you know, epilepsy. So it's that's specific for seizures, but I definitely think that all of those in school first suspected syncope as well. There's probably be a few more for syncope, you know, like standing BP on anything else. But but I think I think it goes with both. Although it was mostly targeted, that seizure, I think that another 1 10 patients come out of status epilepticus on their own. But they can do so. As I said, You know, the brain normally pretty good at shutting down seizures, you know, you have extra electricity, and then there's lots of mechanisms toe stop it. Which is why seizures only last normally for a couple of minutes. Now, the old diagnosis of status epilepticus was on going seizures for 30 minutes. Where is now? We kind of more user cut off of five minutes, because once you get to five minutes, the chance of someone coming out for themselves is lower. But it doesn't mean that it's impossible. Okay, It's just that you don't You're not gonna risk not treating it because the longer it goes on, the harder it is for someone to come out and Stasis. Okay. Uh, I can't see anymore questions popular with chap. Um, so I think unless anyone what's in there is a lot. Thank you. Start to come in now. So, yeah. Thank you very much. Daycare. Our next session, everyone will be on the 21st. So on Monday. And that's more around with managing people with established epilepsy. Um, on D sort of anti epileptics, which is a sort of common situation you can cross. Is the foundation doctor in the hospital. Um, food. So you that please read the words. This is in the neurology Siris. Four months bleep. Yeah, the more the more, the merrier on board. So thank you very much. Daycare. Thank you very much. Everyone to attending with foods get excellent. My