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everybody, uh, I for ask me to do this. Um, I'm fertile down. Any consultants case you don't know who I am. I've been up to just give you a month free on management of status. Epilepticus is part of this. The goals of this really as to we talked a little bit about the definition of status. It's important on brownish little bit. Um, now we talked through the management. We will talk through the theoretical management and then we'll couple through the treatment algorithm on. Then we'll talk with some special special issues that when you just take in the consideration, it's the definitions status. Epilepticus a state of prolonged on control seizures that's a common, very dramatic and department presentation were totally approaches 30% if it's untreated. So it's very important that we treated mortality raises the longer the seizure activity goes on, so it's important to try to get tougher as soon as possible. Um, the traditional definitions of status referred to take one prolonged seizure last longer in 30 minutes for multiple seizures of shortage aeration with phone urological recovery. Cialis a little bit, um, in the most people's have a seizure. The last last moment. A significant proportion. Stations that continue for more than five minutes continue for greater than 30 minutes. So currently are thinking about it is that if a seizure continue more than five minutes, you assume it's going to go on. Progress on to to status. There is evidence your oh, no injury can results. Uh, even just after five minutes of seizure activity. So suppose important thing with that is is we got a standby call, uh, the ambulance career bringing in somebody with the seizure. They haven't just started seizing with the Avonex culture. Been so for the time they're right in the department. Could have already been season for a lot longer than five minutes. So, by definition, by this definition there in status under at risk of your oral injury, uh, we get patients who have seizures in the department on because we know over quite often they're quite short episodes. Last last one minute they felt that criteria. But patients come in a vial minutes back by definition. Generally, unless they're just never, really, I say the hospital of the season for the fact that it's the time they're around with us. Other problems with With status is you get provide lactic and raspberry acidosis. Haven't seen me. A You get after 30 minutes a seizure. You could get most of this tremor after regulation on. Do start getting quite significant, your oral injury. Um, you get massive cortisol kind of coordinating release. You see, the way patients with status are are kind of a hypertensive. The Kennedy frost in the life. Um, you know, So there's a lot. A lot of off the can be hypothermic, a swell just through the problem muscle activity. Um, so it's very important that you realize that you're dealing with something that needs to be. It's a pain dependent thing that you need to try and treat a soon as you can tapes the most dramatic and most common and clinically office presentation. There's a generalist tonic clonic seizure. That's that. They know that their red make muscle contractions every every every every muscle in the body with that transmits the patch teeth on loss of consciousness. Other types of seizures with the partial status seizure. So the definitions of CM it's it's it's so a partial seizures, just focal seizures or arrhythmic rated contraction of singer limb or muscle group, or it can present a sensory illusions or hallucinations are symptoms of depersonalization. Um, and often these presentations. There's no particular older level of consciousness. These are when we're talking about the These are the These don't tend to result and significant problems we do need treated, uh, usually managed with bands it was to begin with. But Anton, um, or eyes the that's the one that tends to cause more problems. The other types of seizures the absence seizure, get my clonus our pseudo seizures thinks we're not going to talk about I mentioned briefly at the end. Okay, common cause of status. Uh, no drug compliance. That's generally generally people who don't have to have epilepsy off a little bit of that alcohol or drug withdrawal over a shinin they're not the epileptic medication and endocrine illness or your old MRI, an injury. Eso, like a summer, actually are somebody who's had a stroke very off your things. Develop new epilepsy six months the energy to do your sister, and, uh then it'll the skin like an injury. Metabolic abnormalities, hypoglycemia on a train. You, uh, co ingestion of drugs that that increased metabolism about the epileptic medication on there for for the seizure threshold. Okay, room a third Spicer apple. Absent people present with Start us one third of chronic apple absi are No. One happened after you find that ready on treatment, and these are the ones that tend to come in in status because they're known compliant or something's happened with the medication or something's changed. Or interpret that list one thirties, New York said epilepsy who have had that for a seizure. We're going developed long term epilepsy, and that's the type of patient. Only make it with a on order brain injury. Such a stroke, UM, 1 30% with water off episode on these, I think probably the most common presentation, and they're usually a drug withdrawal symptoms such as alcohol Profession. It's bands okay or so many of the kids structure brand Andrea stroke stronger right now. Ham Ridge. Our head trauma on certain type proxy for his CNS infection. Meningitis, travel abscess Probably what we see the most. So all the manager management is by investigating and treating simultaneous say, like a whole Emergency department presentations made investigations. You want to get a blood drug use you want and sure that you never forget this. Um, so it's really, uh, retain bloods, including calcium. You want to be a toxicology screen on you wanna blow gas later? Investigations good was once the seizures are controlled, you want to look at you, get a CT, Brean. Look at any of the convulsive levels. Fall, period battles, uh, you might go to consider and lumbar puncture of blood cultures, you think, is that the current list you want to get a good collateral has straight from from Remember what this decision was the first seizure, or or if there's some tissue right there medication or changing that occasion, it's a management approach. In general, it's any CD approach. Hi, Phil. Oxygen Initial assessment. The CB it cardiovascular status is we also get BP. Pulse. Um, you want to get intravenous intra LCS access as soon as possible? Um, that's absolutely vital in the management of this on the M is to start the convulsions as soon as possible, obviously, so we divide the medicine into into three groups. Early status. Early status is defined as 0 to 10 minutes off continuous seizure activity. So that's that's the first. Often people are passed this when they between the teachers will come by ambulance, so they may have had pretty hospital. They have a bottle madonsela on p r D From when you when you come in the US, probably you should consider when they arrive in the department as as, as moments hero for us. Okay, so we start the clock the minute they're right in the department. The first night treatment is with intravenous signature else's bends of the House of Pains. These are really useful, and they will terminate it and 80% of status epilepticus seizures with them about 10 minute period there as a palms are most effective in the one we tend to use, it's tense across blood brain barrier and more quickly. It stays in the CNS longer than other Benzo's effects as its effect. It's more longer acting on the dose is 4 mg. Follow back further dose after 10 minutes. If you've ever drawn it open, it comes a little tiny vial in their refridge in the fridge. It's just a consistency off, honey, you know, it's really difficult to drop that they got it. So if you got a heads up from now, when the service, so he's coming in status. It's probably best to get another phrase. You get it drawn up. Um, then you can if you don't have more as a palm, it wasn't being a shortage, but why? By being used as a com or midazolam if you can't get access, Uh, this is pretty old fashioned treatment going to still there. You can use PERL the high, but those 0.4 miles per kilogram, the same volume of olive oil that's rectal. Now you have together in a big syringe. It's only it's haven't done it in years, but it's still on there on the protocol. So that's the first hand minutes that's called early status. But that hasn't worked after 10 minutes in the department July and established status to testify in this detention stations pan to 90 minutes. Part of the monitoring of this is that you're always thinking a hand, so if you've given your second, if you give your first dose off bends of the pains and you're waiting to give you a second, but I still haven't worked, you should be thinking about going to a drug covered again I want to go on the next. What you don't need next on causing hospital is fan. It'll be used. That's 1.5 mg for kilogram intravenous. Um, 1.5 500. Um so basically for 70 chemo person's by the ground, you don't need to know the patients. Were you gonna able the patient to look for the 70 kg? You can up the dose a bit. Still a glass. You know, the books about it. That's not exact. But he started ground You're not gonna go to for Rome because of hypertension. It's a ResMed, a cardiogenic. So they need to be in a cardiac monitor on. You can't get any more of a resource area. Other other possibilities use force phenytoin being a barbeque or or sodium bulb for it. If you've got this for it, need be thinking ahead, because if they still in status, you're gonna have to learn a C because they'll want to know that if you get a patient, you know, establish status is getting fan of the one under still season. They want to know that because the next stage is that you want them die because they don't even they see your fell because after 60 minutes, they're considered to be in refractory started. Seven applicants, even to first line treatments. They haven't worked. I should have said finito goes in over 15 minutes. So if you got 10 minutes for the fans Oh, so and they're 50 minutes for the family to when you're not at the 60 minutes. The that's not working your interest factory status on these places, the sedation and a rapid sequence induction on. They need to go to a seat here for for sedation. That's just a ah algorithm that we follow. Um, just a few years. She's all right. Um, most seizures will sell. Terminate within, um, five minutes. Like I say, most seizures. Last lesson. One minute. The most want to repeat in five minutes. But that shouldn't delay treatment because you should assume they're going to go on and to start. Uh, so if you can have a seat seven from India, you can establish idea interosseous access to start treatment. If they stop season. You know, that's fine. You you don't know. You don't know if they're going to or not, so it's just going to have it treated. Get senior a base early includes emotionalism. Consultant Base could say See you face when you do a blood gas with these patients, they often have a very severe mixed acidosis. You see, Ph is in the six points. 70. It's nineties. It's a mixed metabolic Risperdal set. Those just usually they don't. They don't tend to event late, particularly well. Another season on there. There's a huge like a pass it load is well, take this age is not the house that there was just the acidosis. Well, correct. If you treat this age is but stop it, stop filling. Uh, there's so much quite profound acidosis that about is what helped terminate the seizures, too, because it just in your own left Emily. So avoid the temptation to give the patients bicarbonate or anything like that. Just let them let them normalize and cells. Once we stop the seizures, the pH can start to write itself pretty quickly. If the patient having a alcohol withdrawal, seizure or perpetration, which often go hand in hand, you need to consider it in the baby powder. Next, you need to check of local er this. Make sure they don't have hypoglycemia country run the risk of giving them the magnetization um, and the other thing to watch out for is rushing treatment. Banzel's don't work immediately detects time to work, so just pretend you a supportive measures your A B C's. I give the treatments of the appropriate time somebody student a grand mal seizure for review with. It's not seems to be settling. Just have to have faith in the treatment. You have to give it time to work because any any percent off seizures will stop with the appropriate dose. Suspensive has pains so rather than Russia given it after another five. But it's just we have a fancy steak coming across. The smoke being barrier have their effect, so it's important to just give him a chance to work. That's all I've got to say. Like I say, it's a very short run through just only algorithm. Any questions? Thanks very much for that was really helpful on ice on three, uh, would escape for a few minutes if you want. Put some questions into the chart box again today, but right. Okay. You have a question. I'm going to be fair. I didn't ask you to talk be after excited, verbal, and okay, let me just worth and mentioned that the gates has been up there for a P l s. And they brought on by fast town or KEPPRA into the rhythm. So it says the head of the Phantom when I, um it's a bit different to the outside, but and lots of studies are suggesting remission, meaning the keppra rather fancy, not speaking, might like 70 and battle when she said, Yeah, we are due to the drug with the circle to drive in the department, but and we do start capital to, you know, you could get it. All right, you're getting off with no questions is often very much That's great with the lungs, the next talk them.