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I'm uh so I'm a neurologist, um uh neurology, academic registrar based in Southwest London. Um, and I want to try and make this, um, well, I think make it interactive. It's going to be a little bit difficult, but we'll walk through things and go through a case because it's always useful to ground knowledge based on cases and people. So we're going to start off with uh this gentleman. So he's a 72 year old right handed man. Um He was found by his wife in the garden, um and appeared to be confused. He had popped out to do some gardening and um she had just found him confused, not really anything more. He has some, uh he has some vascular risk factors. So he's diabetic hypertensive and he's got some arthritis in his knee, having had a knee replacement a couple of weeks ago and he's depressed. Uh He takes um some medicines that you would expect. Metformin for his diabetes, bendroflumethiazide uh for his hypertension and it's all the statin for his hypercholesterolemia. Um And since the operation has been taking some traMADol for some post operative knee pain, he used to be a smoker. Uh he drinks, he drinks alcohol and he, despite being 72 is not yet retired because he works for a family business, driving a school coach. Um by the time he's seen in A and E uh he has normal vital signs, he's oriented, he has some blood in his chin. Uh but the neurological examination is otherwise completely normal. So this is a fairly um fairly standard presentation. Um and we're going to think about what this might be because it could be many, many things. And we need to make ideally the right diagnosis at the beginning and give him the right advice. So, uh what we're going to do is we're going to revise the differential diagnosis of transient loss of consciousness. Um review the, review the definition and management of status epilepticus and understand the definition of epilepsy and think about some potential long term treatment strategies. Um So we're going to go through that. So maybe if you take um I'm going to give you 15 seconds and if you've got a piece of paper or uh online note pad in front of you, just try and drop down uh as many different causes of transient loss of consciousness as you can. Because I think if, if I just talk at you, it will be less useful. Okay. So this is, this is my list and I list uh the causes of of funny DUIs or uh unusual uh neurological events or loss of consciousness and I break them down. It's a neurological and nonurological. So, uh transient ischemic attack is very, very, very unusual cause of loss of consciousness, but it can do funny motor, funny sensory things, funny visual things. Um And if you're not getting a very clear history uh is worth keeping that in the differential tics, a very short lived motor phenomena or vocal phenomena. Um migraine can cause transient neurological problems can cause uh weakness. And there are people who have hemiplegic migraine or migraine with brain stem aura where you get um other focal neurological dysfunction. There are some very rare and unusual movement disorders. The characters, more kinney's a cardiogenic and non Chinese genic dyskinesias that are not really going to talk about anymore. Dystonias can cause transient neurological um uh episodes and uh periods of arm or leg doing funny things. Myoclonus is much shorter and can very, very frequently be mistaken for seizure. Cataplexy is a loss of muscle tone without loss of awareness. Um uh And then you get dissociative seizures or psychogenic nonepileptic seizures depending on um where in the world you are. These get given different kind of different kind of names and then neurogenic causes of syncope and loss of consciousness, particularly colloid cyst, which can, if not detected, can be, can be fatal. Oh, sorry. Uh I'm gonna um I'm just trying to move that. Uh that's better. Um And then the nonurological causes, you've got cardiogenic syncope So primary arrhythmias, vasovagal syncope, which I think most people are aware of um orthostatic syncope, which is where you've just been stood up for a long time. Kind of uh overlaps with vasovagal panic attacks. Don't ever forget, glucose, hypoglycemia can cause uh loss of consciousness and even sustained coma and then toxicity from drugs or alcohol. Uh This is a shame that it's not going to work. Um This is an excellent video if you go onto youtube, if you're able to after, after this talk and just put in um German medical student syncope, you should get this video and uh normally I'd like to try and play this video in its entirety. Um I'm just gonna try present on this device. Hold on, let's see if this works because I think it's a useful um use of time. Uh huh. Are you seeing this video happening? Is a transient loss of consciousness? Yes. Okay. So I'm just going to let you listen to this, uh listen and watch this video for a few minutes because you'll see lots of different unnoticed. So these are all this German healthy German medical students, cardiac or neurological problem studied in six healthy volunteers. And they were asked to hyperventilate syncope maybe safely and induced by a sequence of hyperventilation while squatting, rapid rising and a valsalva maneuver. But off. So if any of you do this, you're likely to faint. Um and then they've all been given instructions to then count to 10. In order to test their responsiveness, subjects are repeatedly asked to count. Uh What you'll see is that there are lots of movements here that could quite easily be mistaken as seizure. About half of the subjects collapsed in a sinking placid way. But try and pick out how many other things that fall extended while falling. Um You can pick up from these videos and again, these are all of these are all that fainting, not seizures. Uh 16, only 10% of the subjects lay motionless during syncope. So if you're asking for uh asking a witness what happened when they collapsed and they said they started jerks and that myoclonus that doesn't mean that they had a seat. My clonus was usually arrhythmic and multifocal. So, so look at the very short jerking of the legs and the arms and that goes on for a few seconds after his collapse. And again, this is not a seizure. This is a simple, a simple faith, mild twitches appeared. So you see that uh adduction of the legs, you can see the need jerking in towards the middle that could quite easily be mislabeled as a seizure. He collapsed and then he was jerking and his legs were jerking in to work from the outside in my clonus was generalized and symmetric. That would be very easy without any other information to think. I think that's uh I think that's a seizure and then you're going to treat someone most itself high frequency burst. So she's making some involuntary groaning there, she's jerking all her limbs. But again, this is a seizure. And what I want to do by showing you this video showed I'm just going to pause it there. What I want to do by showing you this video is show you that you do need to get collateral history. But then you need to really think about the collateral history and you need to know some of the things that suggest your patient has had a seizure or syncope because they're managed in very, very different ways and you need to not make that mistake, uh not going to watch that again. So, a seizure, this is the the current definition from the International League cased epilepsy. A seizure is defined as a transient occurrence of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Um So putting it into some kind of epidemiological perspective, about half of the UK population will. So one in two people in a developed country will have a transient loss of consciousness at some point in their life. That doesn't mean they're going to have a seizure. But one in two people are going to have a loss of consciousness, be that a faint um cardiogenic syncope or seizure or any of the other transient losses of consciousness that we've talked about. Um So it goes down from 50% to 8 to 10%. But bear in mind that that's still one in 10 to 1 in 12 people will have a seizure at some point in their life. Uh And having a seizure doesn't necessarily mean you have epilepsy, but about about one in 26 people, uh that has one seizure has a propensity to have more or does indeed have more seizures again in their life. And at that point, uh it's labeled epilepsy. So, epilepsy, the current definition and these definitions have changed in the past 10 years or so. Um having at least two unprovoked seizures more than 24 hours apart or having one provoked seizure and a probability of further seizures of at least 60% over the next 10 years or the diagnosis of an epilepsy, epilepsy syndrome. So, if as a child, you have uh certain syndromes like driving syndrome or chronic epilepsy or certain genetic conditions like tuberous sclerosis, we know that you will have epilepsy and that then determines treatment. And in some people, for instance, if, if there's a perinatal diagnosis of, of tuberous sclerosis, you may not even wait for them to have a single seizure before starting them on uh anti seizure medication. Um But if there's uh if there's nothing else to find normal imaging, normally, E G uh and one seizure, that doesn't mean you have epilepsy. But if you've had more than one seizure, more than 24 hours apart, then that's the point that you would say somebody has epilepsy. So you've seen this patient in the emergency department, they're back to normal. Um They, you're just waiting for the blood test to come back and suddenly the nurse calls out from the cubicle. Can I have some help, please? And then you run. Uh and you see that you do your A to we approach, I hope by now you've all been taught the A TUI approach A for airway be for breathing, see for circulation, D for disability and E for exposure. So A you see that they're missing the uh the oxygen mask. If they're missing the oxygen mask, then that means that their airway is patent, air is coming I/O. Their breathing pattern is irregular. And despite being on a lot of oxygen, 10 liters of oxygen, uh they're still relatively hypoxic at 90% you can see that his lips and they're blue where they weren't before his eyes are open. He's looking to the right, his head is turned to the right and there is a rhythmic jerking at the elbows more so on the right than the left and both legs are jerking with the feet turned in. And what I would encourage as you start seeing patient's and start seeing uh funny episodes or seizures or anything like it is, don't use jargon because jargon is only useful. If a the person who says it knows what they're talking about and be the person who hears it, knows what they're talking about and they both share the same model of what that word means. So don't say tonic clonic seizure because that has a very specific meaning and if you've got it wrong, um then you're going to mislead the people with whom you're communicating. So I would highly recommend you describe any funny events in the kind of way that I have there because then people can in for specific meanings from that if it's accurate. But also you're just describing what you're seeing rather than giving an overlay of something that you may not be certain about. So with exposure, you then also see some blood around the lips. Uh he hasn't been incontinent and he has a cannula in his, in his anti cubital fossa. So in the front of his elbow. So I want you to have a think now about what you're going to do for this gentleman. You're, you're right there, you're a treating doctor and it's the nurses looking to you for some guidance as to what to do. So I'll give you 10 seconds again to think about what your immediate management would be. Uh huh. Mhm So before we talk about what we're going to do, I'm going to give you a definition. So status epilepticus is a condition resulting either from the failure of the mechanisms responsible for the seizure determination. Uh All from the initially initiation of mechanisms which lead to prolonged seizures. It's a condition which can have long term consequences including urinal death injury and alterations, neural networks. In practical terms, about 95% of seizures self terminate within one minute and about 98% of seizures self terminate within two minutes. So from a practical perspective, any seizure that's still going on beyond two minutes is much less likely to stop of its own accord. And therefore you're going to have to do something to help it stop. The longer you wait to do something, the less effective your treatment is going to be and the more damage there is going to be to the brain of the patient that can be permanent. So um there is no hard and fast rule but certainly most people would now say that by the time someone has been having ongoing seizure activity for five minutes they are in. Uh and this is a bilateral tonic clonic status. Uh five minutes. That's the point where you need to have done something if you haven't already. Um Five minutes of ongoing seizure activity is uh is very damaging to the brain. Um by 30 minutes, there is almost certainly going to be categorical brain damage. Um And if it's a focal status, epilepticus, so not bilateral tonic clonic, but maybe persistent shaking just on one side um with impairment, sorry, without impairment of consciousness. And then you can be a little bit more relaxed, but still you want to be treating it sooner rather than later in terms of what causes status epilepticus. Uh It's different in adults and Children. So, uh adults on this graph of the kind of ready maroon type lines and what you'll see is the majority of cases of status epilepticus occur in adults who have epilepsy and for whatever reason, have got low levels of their regular anti epileptic drugs. Um in Children, it's very different. The overwhelming cause of status and Children is infections. Um uh So between 10 to 40 per 100,000 people per year will have an episode of a safe epilepticus. Um a significant proportion of people. So between one in 20 and one in six people with epilepsy will have status at some point in their life. Um uh But the flip side of what I said before is although the majority of adults who have status are already known to have epilepsy, half of people who have status, it's their first presentation of seizures. So there, as as I mentioned to you before, jargon is very specific and needs to be used only in the right way and in the right context. So let's talk about a bit of jargon. So we're all speaking the same language. A convulsive seizure is, is just that it's a seizure that causes jerking, convulsive status. Epilepticus is usually referring to bilateral tonic clonic seizure with impaired awareness um that has gone on for more than five minutes. Refractory status, epilepticus is when uh too well dosed. Uh doses of the benzodiazepine has been given and the seizure is still ongoing. And super refractory status epilepticus is when it's been going on for, for more than 24 hours despite um appropriate treatment. Uh So this is what you do. The first thing you do is you make sure that there is um uh the first thing to do is to kind of appreciate what's going on and whilst doing everything else, you also need to have some concept of time. So it's worth just like writing down on a piece of paper. What time it all started? Because everyone including season doctors lose all perspective of time when someone's having a seizure. And if you think it's hard for doctors, then it's almost impossible for relatives. And that's just worth bearing in mind when you, um, when you're asking someone, how long did it last? People always massively overestimate how long a seizure lasts simply because it's scary and you're seeing something horrible happening to someone you love and people's concept of time is very, very elastic. So the first thing to do is to make sure that their airway is patent, uh potentially put them in the uh in the recovery position, potentially put in airway. Yeah, drunks like a nasal pharyngeal airway or a Goodell airway, if their consciousness level is very low to make sure they continue to breathe, because that could be one of the leading causes of death. Get some baseline investigations of which the most important is to check the, uh, capillary glucose or the blood glucose because it could be hypoglycemia. And all you need to do is give them some sugar and everything stops and they go completely back to normal. Um, uh, and then the next thing to do is to give some benzodiazepines and we'll come onto that in a second. And if that doesn't work, you do it again. And if that doesn't work, you're going to give them uh an infusion of an anti epileptic drug. And if that doesn't work, they need to be going to intensive care because just like when your computer stops working, you need to do a hard reset, you need to turn it off and on again. And ultimately, that's what intensive care is there to do, given anesthetic drug for at least 24 hours, turn the brain off and turn it on again. Uh And hopefully the seizure has stopped at that point. So, what are you going to do? Um So the uh the benzodiazepines, ideally in a hospital environment, you want to be giving 4 mg of LORazepam uh as a single, as a single dose and then repeating that a few minutes later. If it hasn't worked. A lot of people are very worried about giving 4 mg of LORazepam because they think it will cause excessive drowsiness and cause somebody to lose their airway. But actually the evidence is very robust that you're more likely to have serious adverse events if you don't give the LORazepam, than if you do give the LORazepam and underdosing is not very useful in terms of what to give next. Uh There are, you've got three choices depending on what is available uh in the drugs cupboard and what you're used to giving. Um I have to say my practice has now almost completely gone to using Levitra system for two reasons. One finito in can lead to cardiac arrhythmias during infusion. So you need to have someone on a cardiac monitor. So if you can avoid finito and then it's worth doing that. Being said, I know many of you are from many different countries and it is quite uh an old and therefore very cheap drugs. So it may be all you have available to you but do just be aware that it can cause arrhythmias during a view including bradycardia and heart block valproate is a very effective medication. However, um uh in women of childbearing age who are on a medication long term, it's the most teratogenic of all the anti epileptic drugs. Also, if people have um uh if people have unusual uh mitochondrial forms of epilepsy, it can actually exacerbate it. And if people have liver dysfunction, then it can also be hip path a toxic and then um uh Levetiracetam is one of the, it's not new anymore, but it's one of the newer drugs. Uh, but of all the medications, with the exception of using it in, uh, severe renal impairment, it doesn't cause significant liver dysfunction. It doesn't interact with other medications. It's the least likely to cause, uh, problems in pregnancy. So, my, I'm now just used to using levetiracetam, uh, which goes by the trade name of Keppra and that's dosed at 60 mg per kilogram, uh, to a maximum of 4.5 g as a, as a single infusion loading base. And it works well done. You've successfully treated your patient, you've got them out of status. So what do you do now? Well, we um we are just going to go back. Uh not sure how to go back. Yeah, we said earlier that the definition of epilepsy is uh either seizures of one seizure with a greater than 60% chance of seizure recurrence over the next 10 years or two seizures with in more separated by at least 24 hours. So he's had two seizures within 24 hours. So that we don't satisfy that criteria. But it may be that we think he's at higher risk um than uh than the rest of the population at having more seizures for the next 10 years. And that may therefore guide whether or not we start him on an anti seizure medication, but there's more to epilepsy than just medications. So, in this country, and you'll need to check how things are in your own countries. Um But in this country, if you've had a, a single seizure, you can't drive for six months. And if you have epilepsy, you can't drive for 12 months following your most recent seizure or being established on medication. Uh So you will have to be familiar with what any driving restrictions are within your jurisdiction in the US. I know it can vary state by state. Um You give everyone safety advice and ultimately, what this boils down to is just being aware that a seizure can happen at any time without any warning. And what's the worst that could happen if you're, if you're doing something and have a seizure? Well, for most of the time, it's not really going to cause a problem, you might fall down if you're standing up. Um But where it does matter is people who have epilepsy are at far higher risk of death by drowning than the rest of the population. So the advice I give is to have a shower rather than a bath because if you have a seizure, when you're in the shower, you'll fall down and you might hit your head on the side of the, on the wall or whatever as you fall. But the water is going to continue to go down the plug hole and not cause you to drown. If you're having a bath and you have a seizure, then your head will go under and never come back up um in London, uh the roads are busy, the underground is busy. So I always tell people to stand well back from the edge just in case they do have a seizure, you don't want them falling into the road or onto the tracks. Um And the other thing to always recommend people do is when they do go and see a neurologist to take an eye witness with them because by definition, if you've lost consciousness, you can't give a very good history of what happened. There's no reason not to swim. Even though I have just said people are higher risk of drowning, but it is worth telling uh the lifeguard that you've had seizures in the past. But swimming is really important because people who have epilepsy. A also tend to have um worse control over um vascular risk factors because they don't do exercise often because they're scared of doing so. Um And likewise, if you're looking after Children, uh you just need to have a think what would happen if I had a seizure. If you're carrying hot pans around the kitchen, what could happen? Um I tell people not to drive, I tell people not to climb ladders or um go up high to change their curtains or change a light bulb or something that's usually a neighbor or friend or relative that you can ask to do stuff like that. And if you have been given anti seizure medication, don't stop taking it of your own accord. So we've talked about driving and let's think back to the beginning. Remember that he was a 72 year old, he would drive a school coach. The worst possible thing that could happen was for him to be to carry on doing that because no one's told him not to. And then he has a seizure while he's behind the wheel and doesn't just kill or injure himself, but takes 30 Children with uh for those of you that live or work or practice in the UK. This is the link to find out what the UK um uh limitations are. So for him, uh if you've had an epileptic seizure, you're not allowed to have a passenger carrying vehicle license for five years and you have to have been off medication for five years as well. Um If you are uh for a regular car license, um you need to have not had a seizure for six months. Uh And the licensing authority need to be happy. You're not at higher risk. So, what do we do now? Well, let's look at the blood tests that you sent when he came in. So he's slightly anemic with a macro cytosis, so large red blood cells, but not enough of them. His white blood cell count is normal. His crp is normal. So we don't think this has been caused by an infection. His sodium is a little bit low but not his sodium is categorically low, but it's not low enough for hyponatremia to be the cause of his seizures. Um and he has some renal impairment. His calcium and magnesium are normal. Those are always worth checking because those can cause seizures. His thyroid function is normal and his ct scan of his head shows some small vessel disease and age related atrophy. Um but the small vessel disease might be important. So, what would you do? Well, that hyponatremia can't be left alone. It needs treating. Um and it needs treating not too fast because that can cause osmotic demyelination. The traMADol, if you think back to what that first slide where we talked about him, that traMADol is really important. TraMADol is a opiate derivative and it's a very dirty drug. It's a horrible drug. Um And it's one of the leading causes of drug and do seizures in that it doesn't cause the seizures, but it lowers your seizure threshold significantly. Um So his seizure wasn't because of the traMADol, but he was more likely to have a seizure because he's on traMADol. He should probably be advised to drink a lot less alcohol and start vitamins. Note that his MCV is 100 and three and on subsequent testing, his uh he had um low vitamin B 12 so that needs replacement. Um and he needs to be seen. Uh He needs to be seen by a neurologist. So I just want to quickly talk about what epilepsy means and how it can be defined. And there are some uh again, relatively new ways of defining different kinds of epilepsy. But epilepsy is not the only thing about a patient. There is the whole of the rest of their life and there is the whole of the rest of their um medical history that needs to be conceptualized and considered when treating as well. So these other co morbidities are crucially important and they should be crucially important to all of us as we treat people with epilepsy. Um So we uh we now define epilepsy as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neuro biologic, cognitive, psychological and social consequences of this condition, it is more than just seizures. Epilepsy is something that you really need to consider the whole person. Therefore, your management must address the cognitive and psychological comorbidities as well as the seizures. Um They are the rule rather than the exception, cognitive complaints, low mood, psychiatric dysfunction are all common in people with epilepsy and you can't ignore them or hope that someone else deals with them. Epilepsy is really important and it kills people. So the standardized mortality rate is uh 1.624 in developed countries and five in developing countries. So you're in a, in a developing country and I know some of you uh likely to live and work in, in developing countries. Someone with epilepsy is five times more likely to have an early death than a non epileptic uh appear of. There's um and things that cause death in epilepsy. A Sudip. So that stands for sudden unexpected death in epilepsy status. Epilepticus drowning, which I've already mentioned trauma or motor accidents um caused by a seizure, falls and burns, um an aspiration pneumonia where they have a seizure and vomit or uh something might go down into their lung instead of down their esophagus. People with epilepsy often have undiagnosed, under diagnosed or poorly managed comorbidities as we've already related as we've already discussed. Um but also there might be uh conditions that have specifically lead to them having epilepsy. So, if you have a brain tumor, either as a primary brain tumor or a metastatic tumor, that's led to your um uh that's led to you having epilepsy. But that could also be what leads to your death. Cerebrovascular disease is one of the commonest causes of epilepsy in older people. Um And infections can cause can, can be fatal. Um The treatment that you give can um cause significant side effects including death. So we talked about valproate causing full and liver failure. Various other medications can cause a plex, a plastic anemia. Uh There can be drug drug interactions and you need to be thinking about all of these. And then people who have epilepsy are more likely to die of ammonia. They're more likely to die of suicide because of untreated uh under managed mental health problems. Um And for reasons that are not entirely clear, they're more likely to have uh all cause mortality from cancer as well. So, what do we, what are we going to recommend to him? Well, this is, this slide is a, I think just an interesting graph for you to see. It's the number of, it's the available licensed anti seizure medications. Um, by year of introduction. So if you, if you go back 100 and 50 years, epilepsy was defined as 21 of two types, there was bromide responsive or bromide unresponsive epilepsy. Then about 100 and 10 years ago, we, we got PHENobarbital, which is still used around the world today. But in the developed world since then, you've had this huge explosion, this mushrooming of, of new anti seizure medications and you don't necessarily need to know about them all. Um, even, I don't know too much about, uh, some of them. Um, but there are lots and lots of medications to choose from and your job as a, as a general physician or is an emergency physician or as, as the first treating doctor or GP isn't to choose the best medication for them, but to send them to someone who does understand these medications better, uh, to pick the right medication for all those other comorbidities and for all those other lifestyle factors that we discussed. Epilepsy, just like most medicine is now an area of joint decision making rather than I'm the doctor. I know best. This is what I shall do. Uh And then hopefully your patient's going to have uh access to an epilepsy nurse or uh or uh an easy point of contact for someone who knows about their condition and can support them. And there are other things that you want to be thinking about as a neurologist, things like bone health, social support and helping your patient really understand their own condition to help self management. And that can also increase uh the compliance or concordance that they have with medication. And I think um I think that's got me to the end of the slides that, that I've got, these are all quite useful um quite useful resources. I know that the I LAE the International League against epilepsy have got a lot of uh learning materials on their website. Um and epilepsy action and the epilepsy society of both patient charities, but have a huge amount of really good and useful information on them that you can look at nice as the National Institute of Clinical Healthcare and Excellence. Um and is one of the one of the statutory bodies in the UK that looks at um kind of summarizing evidence and especially cost effectiveness. Um And even if you're not working the UK, it might be worth you having a look at those. And the D D L A is the Uk's driver and vehicle licensing agency. Which may be of, of uh less use to you if you're not working in the UK. Uh, and with that, I think, um, that's all I've got in terms of slides. If there are any questions, I'm more than happy to answer questions. I've galloped through and I, I hope that it's been of some use and I apologize for starting late. Thank you. Yeah, you're very welcome. Any questions? Thank you very much, doctor. Um If anyone has any questions, you want to mute yourselves. All right, in the chat, we do have about 10 minutes before the next lecture. So please take the chance to ask any questions. Now, I've got the chat open. So if you, if you type something in there, if you don't want to um meet yourself, then I'll be able to have a look. Yeah, night. Well, I'll tell myself that that's because you've uh learned everything you could possibly want to, to learn. Um I'm sure I'm sure you haven't. I'm sure you have questions. Uh If uh if anyone wants to send some questions through by email, I'll be happy to have a look at them. Um But I've tried to make this uh interesting journey through a patient's um presentation and then what to think about long term. I think epilepsy is a really interesting condition to learn about interesting condition to treat. There are all sorts of different reasons why people can have seizures. But I think my one of my take home messages for you would be um not everything that falls over and shakes is epilepsy. Um And epilepsy is a, is a very broad umbrella term that actually means an awful lot of different things to an awful lot of different people. And you need to treat each of your patient's as a, as a individual and treat them holistically um to give them the best treatment and the best possible life. Uh an epilepsy is something that can be very, very well treated and managed such that you can um effectively render 70% of people completely seizure free with the right medication. Um With that, thank you very much and enjoy the rest of your day. Mhm.