WEBVTT 1 00:00:01.080 --> 00:00:03.960 All right, so moving along with the neurosection, we're going to talk about 2 00:00:04.000 --> 00:00:06.559 seizures today. Decent amount of material for you to know. I do have 3 00:00:06.559 --> 00:00:10.480 some mnemonics in there to help you remember the important stuff. So thank you 4 00:00:10.519 --> 00:00:13.679 as always for the support, the really nice comments. I do appreciate every 5 00:00:13.679 --> 00:00:17.000 single comment and everything. I just really appreciate the support, So thank you 6 00:00:17.039 --> 00:00:19.640 so much for that. Let's talk about seizures. So first let's go over 7 00:00:19.679 --> 00:00:24.280 the definition. The official definition would be a sudden change in behavior caused by 8 00:00:24.559 --> 00:00:29.839 electrical hypersynchronization of neuronal networks in the cerebral cortex. So that's a lot of 9 00:00:29.879 --> 00:00:34.520 different words. Let's actually talk about what that means. So neurons are synchronously 10 00:00:34.600 --> 00:00:38.240 active, so all the neurons they're firing together. They're not supposed to be. 11 00:00:38.759 --> 00:00:42.439 Whether this is caused by too much excitation, caused by problems with the 12 00:00:42.880 --> 00:00:47.679 NMDA receptors, too little inhibition with defective GABA receptors, the effect is the 13 00:00:47.719 --> 00:00:52.320 same. You have neurons firing inappropriately NonStop, which causes a number of clinical 14 00:00:52.359 --> 00:00:57.320 manifestations. Will go over. Now, there's some causes of seizures that you 15 00:00:57.359 --> 00:00:59.840 should be aware of. I don't expect you to re memorize all of these. 16 00:01:00.000 --> 00:01:02.759 But there is anemonic that I've come across that's not my own, but 17 00:01:02.799 --> 00:01:06.439 it's called vitamins, and it stands for some of the more common causes of 18 00:01:06.799 --> 00:01:11.640 your provoked seizure. So vitamin stands for v vascular, so vascular malformation, 19 00:01:11.719 --> 00:01:15.400 stroke, I stands for infections, meningitis, and cephalalitis. T stands for 20 00:01:15.480 --> 00:01:21.280 trauma, so like a traumatic brain injury, a autoimmune think lupus. M 21 00:01:21.359 --> 00:01:25.480 stands for metabolic, so I think low blood sugar. Most low electrolytes can 22 00:01:25.519 --> 00:01:30.280 cause seizures, so hypocalcemia hyponatremium. I stands for ingestion, so whether it's 23 00:01:30.400 --> 00:01:34.400 ingestion of toxins like drugs which lead to the seizure, or withdrawal from ingestion 24 00:01:34.439 --> 00:01:38.719 of certain toxins like alcohol withdrawal which can lead to seizures. ND stands for 25 00:01:38.799 --> 00:01:44.280 neoplasms like brain tumor. And then the S stands for the second letter in 26 00:01:44.439 --> 00:01:49.000 psych so psychogenic. So non epileptic seizures think conversion disorder. Now let's talk 27 00:01:49.000 --> 00:01:52.400 about the different types of seizures. The first thing that I wanted to go 28 00:01:52.439 --> 00:01:55.959 over is the definition of epilepsy because we're going to be thrown around that word 29 00:01:55.959 --> 00:01:59.439 a lot. So to make the diagnosis of epilepsy, there's some criteria to 30 00:01:59.480 --> 00:02:02.439 meat and most cases, though epilepsy just means you've had recurrent seizures, but 31 00:02:02.519 --> 00:02:07.800 the official diagnostic criteria is either two or more unprovoked seizures occurring more than twenty 32 00:02:07.840 --> 00:02:12.080 four hours apart. Unprovoked means it wasn't caused by one of the vitamins we 33 00:02:12.120 --> 00:02:14.599 just went over, so it wasn't a low blood sugar or an infection that 34 00:02:14.639 --> 00:02:19.759 caused it, etc. Another criteria would be one unprovoked seizure and a high 35 00:02:19.840 --> 00:02:22.919 risk of recurrence. So a patient that only had one seizure but has a 36 00:02:22.960 --> 00:02:27.840 high risk of second seizure can be diagnosed with epilepsy and high risk meaning they 37 00:02:27.879 --> 00:02:30.719 had a stroke, traumatic brain injury, brain tumor things that are going to 38 00:02:30.759 --> 00:02:32.159 put them on a high risk for a second one. And then the third 39 00:02:32.240 --> 00:02:38.159 one is kind of nonspecific identifiable epilepsy syndrome, So this is either genetic or 40 00:02:38.199 --> 00:02:43.960 idiopathic epilepsy. So that's epilepsy. Now let's talk about different specific types of 41 00:02:44.039 --> 00:02:49.840 seizures. So most seizures can be categorized by either focal or generalized depending on 42 00:02:49.960 --> 00:02:53.639 where they affect. So when just one hemisphere of the brain is affected, 43 00:02:53.680 --> 00:02:57.080 just half the brain, or even just one low this is called a focal 44 00:02:57.159 --> 00:03:02.479 seizure, and then in generalize seizures both sides of the brain are affected simultaneously. 45 00:03:04.120 --> 00:03:08.960 Focal seizures can be categorized further depending on whether or not consciousness is altered 46 00:03:09.280 --> 00:03:14.199 during the event, so you have focal seizures with retained awareness. These used 47 00:03:14.199 --> 00:03:16.879 to be called simple partial seizures. He may still hear them, being called 48 00:03:16.919 --> 00:03:22.479 that the presentation will be unique in each patient with this type because it really 49 00:03:22.479 --> 00:03:24.599 all depends on the part of the cortex that's affected at the onset of the 50 00:03:24.599 --> 00:03:30.240 seizure. So if it affects the occipital cortex, it may result in flashing 51 00:03:30.319 --> 00:03:34.400 lights. The frontal lobe can cause sudden speech difficulties. There may be changes 52 00:03:34.400 --> 00:03:38.960 in hearing and taste. It's possible to have involuntary movements or jerking movements the 53 00:03:38.080 --> 00:03:43.120 key though, as the name suggests, generally they will retain awareness or their 54 00:03:43.120 --> 00:03:46.960 consciousness during the episode, so they should have retained awareness during this type of 55 00:03:46.960 --> 00:03:50.759 focal seizure. The other type of focal seizure is impaired awareness, used to 56 00:03:50.759 --> 00:03:54.960 be called complex partial. So during a typical focal seizure with impaired awareness, 57 00:03:55.120 --> 00:03:59.280 the patients may appear to be awake, but they're not going to respond to 58 00:03:59.360 --> 00:04:02.199 normal and struggles or questions. They may stare into space, they may remain 59 00:04:02.240 --> 00:04:08.319 motionless, engage in repetitive behaviors. These are called automatisms. They can include 60 00:04:08.319 --> 00:04:12.240 facial grimacing, lip smacking, etc. So their behavior is altered in some 61 00:04:12.319 --> 00:04:15.120 way. And then afterwards, most of the time these patients are going to 62 00:04:15.240 --> 00:04:18.319 enter what's called the post Ichtl phase and during this time they may have confusion 63 00:04:18.399 --> 00:04:23.040 headache for up to several hours. All right, so let's talk about generalized 64 00:04:23.040 --> 00:04:26.439 seizures now. So if generalized seizures, again, both hemispheres of the brain 65 00:04:26.480 --> 00:04:30.759 are going to be affected and in most cases these types of seizures will involve 66 00:04:30.839 --> 00:04:34.480 some degree of altered consciousness. Not always but most cases. So there's different 67 00:04:34.480 --> 00:04:39.560 types of generalized seizures. The most common, though by far the most common, 68 00:04:39.560 --> 00:04:43.240 type of generalized seizure is going to be one called a tonic clonic, 69 00:04:43.439 --> 00:04:47.120 also known as a grand mall seizure. So most common generalize seizure. It's 70 00:04:47.160 --> 00:04:50.759 basically what everyone thinks of when they think of the classic seizure presentation. So 71 00:04:50.839 --> 00:04:55.199 let's go over what that involves. So, tonic clonic grandmall seizures, what 72 00:04:55.240 --> 00:04:59.399 does this mean? So first let's understand what the terms tonic and chlonic mean. 73 00:05:00.160 --> 00:05:03.600 Tonic means rigidity or a sudden muscle stiffening. The muscles get stiff. 74 00:05:03.920 --> 00:05:08.800 Sometimes they can stay contracted or stiff up to a minute or two during this 75 00:05:08.920 --> 00:05:12.639 tonic phase. And then the second part of this is the klonic phase, 76 00:05:12.680 --> 00:05:15.759 which means rhythmic jerking muscle contractions. It's usually going to be of the arms, 77 00:05:15.839 --> 00:05:18.480 neck, and face. So a tonic chronic seizure, you put those 78 00:05:18.480 --> 00:05:23.160 together, usually begins with an abrupt loss of consciousness. This is followed by 79 00:05:23.160 --> 00:05:26.240 the tonic phase where all the muscles become stiff. Then after a minute or 80 00:05:26.240 --> 00:05:29.959 so, the muscles begin to jerk twitch for an additional one to two minutes, 81 00:05:29.959 --> 00:05:31.879 and that's your klonic phase. And this is normally followed by a post 82 00:05:31.920 --> 00:05:34.759 Ichtl phase. All right, so a tonic chronic that's the big one you 83 00:05:34.759 --> 00:05:38.680 need to focus on. Let's talk about some other types of generalize seizures that 84 00:05:38.720 --> 00:05:44.040 may come up. So myoclonic. Myoclonic is normally going to involve either a 85 00:05:44.079 --> 00:05:46.639 single muscle, sometimes a group of muscles, and it's just a brief contraction, 86 00:05:46.680 --> 00:05:50.040 like a just a quick jerking motion, a really quick contraction of a 87 00:05:50.120 --> 00:05:54.519 muscle, then it stops. Most commonly it's going to involve the arms, 88 00:05:54.800 --> 00:05:59.680 and consciousness is usually not impaired in this type klonic just like we went over 89 00:05:59.720 --> 00:06:03.600 in time klonic seizures. Chlonic portion causes rhythmic jerking and muscle contractions that usually 90 00:06:03.600 --> 00:06:08.199 involve the arms, neck, and face. Tonic, just like we just 91 00:06:08.199 --> 00:06:11.959 went over, usually a sudden muscle stiffening, so the muscles get stiff, 92 00:06:12.600 --> 00:06:15.519 often associated with a loss of consciousness. The way that I used to remember 93 00:06:15.560 --> 00:06:17.240 what tonic meant, because there's so many different names, sometimes you can get 94 00:06:17.240 --> 00:06:20.600 confused. So as soon as I see tonic seizure, I think of a 95 00:06:20.680 --> 00:06:25.000 gin and tonic, and the gin in tonic is a stiff drink. So 96 00:06:25.040 --> 00:06:27.319 as soon as you see tonic, think of a gin and tonic, which 97 00:06:27.360 --> 00:06:30.319 you know as a stiff drink, and then it helps you remember tonic seizures 98 00:06:30.319 --> 00:06:33.800 cause muscle stiffening. And then the next type is called an atonic seizure. 99 00:06:33.839 --> 00:06:36.759 So if you can remember what a tonic seizure is, you can remember what 100 00:06:36.800 --> 00:06:42.040 an atonic seizure is because it's the exact opposite. So atonic means the muscles 101 00:06:42.079 --> 00:06:45.839 basically turned to jello, so the opposite of stiffening like in tonic. So 102 00:06:45.879 --> 00:06:48.759 these individuals with atonic seizures will have a sudden loss of control of the muscles. 103 00:06:48.759 --> 00:06:51.240 Commonly, this is going to involve the legs and it's going to cause 104 00:06:51.240 --> 00:06:56.120 these patients just to collapse. They'll be conscious in most cases, they'll just 105 00:06:56.120 --> 00:06:58.839 lose control of their muscles and just drop to the ground. And that's why 106 00:06:58.879 --> 00:07:01.759 you sometimes hear these being called drop seizures because their legs turn to jello and 107 00:07:01.759 --> 00:07:04.279 they just drop to the ground. So if you can remember what tonic is, 108 00:07:04.319 --> 00:07:06.319 you can remember what a tonic is, and you can knock out two 109 00:07:06.399 --> 00:07:11.639 right there. And then the last one is something known as absence seizures or 110 00:07:11.680 --> 00:07:15.120 absent seizures. I think the correct way is absons, though these used to 111 00:07:15.120 --> 00:07:17.480 be called petite mall seizures. Usually you're going to see these in children. 112 00:07:17.600 --> 00:07:20.319 And what happens in these children is they'll be in class, they'll be at 113 00:07:20.360 --> 00:07:23.560 home, they're doing fine, no issues, and then all of a sudden, 114 00:07:23.560 --> 00:07:26.920 they'll just be staring. They'll have the state of impaired consciousness. They 115 00:07:26.959 --> 00:07:30.680 won't respond to any verbal or tactile stimuli. During these episodes. They may 116 00:07:30.720 --> 00:07:33.759 also have eyeblinking and lip smacking. This can occur hundreds of times per day, 117 00:07:34.000 --> 00:07:38.319 and typically each episode will last between five to ten seconds. A lot 118 00:07:38.360 --> 00:07:43.800 of times it's misdiagnosed as ADHD. So again absence seizure, no loss in 119 00:07:43.879 --> 00:07:47.959 muscle tone, but impaired consciousness for just brief periods. No Abson seizures. 120 00:07:48.160 --> 00:07:53.199 Very well, You're going to be tested on this because it has a unique 121 00:07:53.199 --> 00:07:57.319 presentation and has a specific first line med which will go over and like all 122 00:07:57.480 --> 00:08:00.639 unique things with specific first line meds, you're always going to get tested on 123 00:08:00.680 --> 00:08:03.079 them. So make sure you know abs on seizures. I have a little 124 00:08:03.120 --> 00:08:05.759 mneumonic for you to remember the treatment too when we go over that. And 125 00:08:05.800 --> 00:08:09.639 then the last type of seizure or not so much a specific type of seizure, 126 00:08:09.759 --> 00:08:13.240 more just a seizure that lasts two damn long is status epilepticus. So 127 00:08:13.480 --> 00:08:20.199 the official diagnosis or the official definition of status epilepticus is an unremitting generalized convulsive 128 00:08:20.199 --> 00:08:26.680 seizure lasting longer than five minutes, or multiple bilateral convulsive seizures without a return 129 00:08:26.720 --> 00:08:31.200 to baseline level of consciousness. So either this patient has a single seizure the 130 00:08:31.240 --> 00:08:35.600 lasts over five minutes, or they have more than one seizure without recovery between 131 00:08:35.600 --> 00:08:41.159 each episode. Some medical neurological emergency neurons are firing NonStop, they're essentially frying 132 00:08:41.200 --> 00:08:43.879 their brain. Have to board the seizure quickly, and these patients are going 133 00:08:43.919 --> 00:08:46.879 to need prompt treatment, and we'll go over the treatment protocol in a minute. 134 00:08:46.879 --> 00:08:50.360 This is another one that you really need to know now diagnosis. So 135 00:08:50.639 --> 00:08:54.879 with diagnosis, you're obviously going to start with a very thorough history. It 136 00:08:54.960 --> 00:08:56.519 a lot of times this will be obtained from a friend or family member that 137 00:08:56.559 --> 00:09:00.600 witnessed the seizure. You'll need to find out was there any trauma, is 138 00:09:00.600 --> 00:09:03.759 there any drug or alcohol use. Most patients with epilepsy, though, are 139 00:09:03.759 --> 00:09:07.399 going to have a fairly unremarkable clinical history, and then of course you want 140 00:09:07.399 --> 00:09:11.240 to have a very thoroughphysical exam, including a neuroexam, and then let's talk 141 00:09:11.240 --> 00:09:16.440 about your initial lab work. So your initial laboratory tests. You're definitely gonna 142 00:09:16.440 --> 00:09:18.679 get a rapid blood glucose. You want to make sure this isn't hypoglycemia. 143 00:09:18.919 --> 00:09:22.000 You're going to get a CBC. CBC you're looking for signs of infection. 144 00:09:22.679 --> 00:09:26.559 You want to get a CMP, and the CMP you're checking electrolytes. You 145 00:09:26.600 --> 00:09:30.759 want to make sure this wasn't from hypocalcemia hyponatremia. You're also checking your renal 146 00:09:30.759 --> 00:09:33.320 function with this your LFTs, and then you want to do your analysis in 147 00:09:33.399 --> 00:09:37.159 a toxicology screen. So a lot of different things basically to search for those 148 00:09:37.240 --> 00:09:41.799 vitamins we went over earlier. You're looking for a potentially reversible cause, so 149 00:09:41.919 --> 00:09:45.399 be aware of those different lab tests. I wouldn't say to memorize all of 150 00:09:45.440 --> 00:09:48.159 them, just have a general overview. One lab though, that I do 151 00:09:48.200 --> 00:09:52.720 want to go into a little bit more detail about is serum lactate. So 152 00:09:52.759 --> 00:09:58.360 cerum lactate is a good lab to obtain in a patient who had an unwitness 153 00:09:58.679 --> 00:10:01.879 transient loss of con bousness, so no one to say that, yeah, 154 00:10:01.919 --> 00:10:05.039 they were seasoned convulsive flowling their arms, et cetera, that you suspect may 155 00:10:05.039 --> 00:10:09.840 have had a seizure because a serum lactate, if it's elevated in the first 156 00:10:09.840 --> 00:10:13.360 two hours after the event, this essentially confirms that it was a generalized seizure 157 00:10:13.480 --> 00:10:18.720 rather than some other cause, just like a regular syncople episode or a psychogenic 158 00:10:18.759 --> 00:10:22.559 non epileptic seizure. So another one that you may have you may hear of 159 00:10:22.639 --> 00:10:26.440 is serum prolactin. It's another lab that you can use, but it's not 160 00:10:26.559 --> 00:10:30.919 as sensitive or specific as a serum lactate and it's usually not recommended as part 161 00:10:30.919 --> 00:10:33.039 of the routine eval. But cerum lactate is definitely an important one that you 162 00:10:33.039 --> 00:10:37.480 should know. Neural imaging, so whether this is an MRI or CT in 163 00:10:37.519 --> 00:10:41.360 a patient with their first seizure, you have to get some imaging of the 164 00:10:41.399 --> 00:10:45.080 brain. You want to make sure there isn't any brain abnormalities intracranial neoplasma, 165 00:10:45.080 --> 00:10:48.320 et cetera. MRI is going to be preferred, it's the better test, 166 00:10:48.399 --> 00:10:52.000 but CT is another alternative. And then let's talk about our egs. So 167 00:10:52.159 --> 00:10:56.600 once you've ruled out your vitamins, this isn't from you know, vascular stroke, 168 00:10:56.639 --> 00:11:00.159 confection, meningitis and cephalitis, et cetera. You want to obtain an 169 00:11:00.200 --> 00:11:05.919 EEG and electron cephalography. It's not one hundred percent sensitive, but if it 170 00:11:05.039 --> 00:11:09.000 is abnormal, it can help support the diagnosis of an epileptic seizure, and 171 00:11:09.039 --> 00:11:13.519 it can also help distinguish between generalized or focal seizures. General there's not a 172 00:11:13.600 --> 00:11:18.039 lot to know about the specific findings for an EG except from one thing. 173 00:11:18.320 --> 00:11:22.639 If you see an avignette they mention a three hurts, spike and wave pattern 174 00:11:22.399 --> 00:11:26.159 right away, be thinking absent seizure. I wouldn't worry so much about why. 175 00:11:26.320 --> 00:11:30.240 Just know if you see three hurts, spike and wave pattern a vignette, 176 00:11:30.440 --> 00:11:33.679 the answer is absent seizure. As you're done, so remember that. 177 00:11:33.000 --> 00:11:37.320 So if your diagnostic studies again, remember three things. Neuroimaging MRI I preferred 178 00:11:37.320 --> 00:11:41.480 over CT, your labs, checking electrolytes, blood, glucose, etc. 179 00:11:41.840 --> 00:11:45.360 And then an EEG. That's the three main things to focus on for diagnosis. 180 00:11:45.759 --> 00:11:48.879 Let's talk about treatment now. So with anti elleptic medications, there's really 181 00:11:50.000 --> 00:11:54.879 no first line meds quoted from up to date, no single anti seizure medication 182 00:11:54.000 --> 00:11:58.519 is clearly the most effective or best tolerated. So in general they're not going 183 00:11:58.559 --> 00:12:03.000 to list four or five different seizure meds and say which one would you pick. 184 00:12:03.360 --> 00:12:05.960 There is some exceptions. I'm going to go over those, So this 185 00:12:05.000 --> 00:12:09.720 isn't one hundred percent like an absence will go over. There is a first 186 00:12:09.759 --> 00:12:13.440 line MEN obviously, and there's some other specific circumstances I'll go over. But 187 00:12:13.519 --> 00:12:16.559 in general, there's really been a lot of studies and they don't really find 188 00:12:16.559 --> 00:12:20.279 one seizure men to be better than another. Again, there are some exceptions. 189 00:12:22.519 --> 00:12:26.600 The most important thing though about anti seizure medication is knowing specific adverse drug 190 00:12:26.600 --> 00:12:28.519 reactions, so they could ask you something related to that. It's not so 191 00:12:28.600 --> 00:12:31.440 much again about which med's going to work best to prevent the patient seizure, 192 00:12:31.679 --> 00:12:35.720 but which med will be safest considering the patient's comorbidities and things like that. 193 00:12:37.120 --> 00:12:39.519 Now, most patients with their first seizure, they're not going to require anti 194 00:12:39.559 --> 00:12:43.840 elliptic medication. These patients that you're going to start on anti elliptic medications are 195 00:12:43.960 --> 00:12:48.320 specific specific patients. So for instance, patient with two or more seizures, 196 00:12:48.360 --> 00:12:52.679 because then by definition, these patients have epilepsy and each treatment or a patient 197 00:12:52.759 --> 00:12:58.159 that you would start anti seizure medications with only one seizure their first seizure are 198 00:12:58.159 --> 00:13:01.919 patients that have a high risk for a second. So again like we went 199 00:13:01.960 --> 00:13:05.080 over before, they have a high risk finding like maybe a brain tumor, 200 00:13:05.120 --> 00:13:09.639 they had a stroke, head trauma, abnormal neuroexam with focal findings, and 201 00:13:09.720 --> 00:13:13.159 abnormal EEG. These are all high risk findings and if these patients it'd be 202 00:13:13.200 --> 00:13:18.279 acceptable to start them on meds with just one seizure. Another situation where you'd 203 00:13:18.279 --> 00:13:22.120 start a patient on anti seizure medications with just one seizure would be if they 204 00:13:22.120 --> 00:13:26.720 wound up going into status epilepticus, because these patients are at very high risk 205 00:13:26.759 --> 00:13:31.240 for a number of problems. So those are the patients you'll start most patients, 206 00:13:31.279 --> 00:13:33.960 so with their first seizure, you're not going to start on anti seizure 207 00:13:33.000 --> 00:13:37.919 medications. Just be aware of some of those circumstances where you would. So 208 00:13:37.000 --> 00:13:43.679 let's first talk about two types of seizures where there is a specific first line 209 00:13:43.799 --> 00:13:48.759 therapy, So there's a couple different meds that you need to know for these 210 00:13:48.799 --> 00:13:50.600 and these different types of seizures are really the ones that you need to focus 211 00:13:50.600 --> 00:13:54.840 on for your exam because these are likely where a lot of your questions will 212 00:13:54.840 --> 00:13:58.279 come from when we're talking about medications. So the first one we need to 213 00:13:58.320 --> 00:14:00.879 go over. It is probably the most important type of seizure for you to 214 00:14:00.879 --> 00:14:03.720 know. Questions always seem to be asking about this, and that's absent seizures. 215 00:14:03.919 --> 00:14:07.519 So for absent seizures, you have a first line medication you absolutely have 216 00:14:07.559 --> 00:14:11.639 to know, and that's Etho sucks a mine. That's your first line med 217 00:14:11.759 --> 00:14:13.799 Etho sucks, Etho sucks and mine, however you want to pronounce it. 218 00:14:15.360 --> 00:14:18.320 That is your first line medication for absent seizures. Second line med would be 219 00:14:18.360 --> 00:14:22.960 valpro eight. I normally don't recommend memorizing a second line med just because you 220 00:14:24.000 --> 00:14:28.200 have so many medications memorize anyways. But the thing is that I was asked 221 00:14:28.360 --> 00:14:31.399 in school, so I feel like you should probably know it because maybe it'll 222 00:14:31.399 --> 00:14:33.639 come up for you too, And I do have a way for you to 223 00:14:33.720 --> 00:14:35.879 remember both. So an absence seizures, your first line again, it's going 224 00:14:35.879 --> 00:14:39.759 to be Etho sucksomides. Second line is going to be valpro eight. The 225 00:14:39.799 --> 00:14:43.519 way that you remember that hopefully you've heard this expression. But there's an expression 226 00:14:43.559 --> 00:14:46.120 that's known vanishing into the ether. And it's like when you're just gone, 227 00:14:46.159 --> 00:14:50.639 you're absent, somebody like disappear. They vanished into the ether. So the 228 00:14:50.679 --> 00:14:54.559 way that I remember absent seizures medication regimen is I remember if you're absent, 229 00:14:54.720 --> 00:14:58.759 like absent seizure. If you're absent into the ether, you will vanish. 230 00:15:00.080 --> 00:15:03.759 If you're absent, like in an absent seizure, into the ether, you 231 00:15:03.799 --> 00:15:09.120 will vanish. And that sentence is in order because ether comes first and ether 232 00:15:09.240 --> 00:15:13.279 is the first three letters in Etho sucks amine. So ether you will vanish 233 00:15:13.799 --> 00:15:16.399 and then vanish. The second word is your second line med and that's valpro 234 00:15:16.480 --> 00:15:20.360 eight, So that's va and vanish. That's your first couple of letters of 235 00:15:20.399 --> 00:15:24.080 valpro eight. So if you're absent into the ether, you will vanish. 236 00:15:24.120 --> 00:15:28.720 And that's how you remember your first and your second line meds for absent seizures. 237 00:15:28.720 --> 00:15:31.559 Remember again Atho suximide, first line, Valpro eight, second line. 238 00:15:31.600 --> 00:15:33.840 If you're absent into the ether, you will vanish. Then the second thing 239 00:15:33.879 --> 00:15:37.960 that you really need to know a specific medication regiment is for status epilepticus. 240 00:15:39.320 --> 00:15:41.600 Remember status epilepticus, a seizure, then I went on for two dam long. 241 00:15:41.720 --> 00:15:46.200 So the first thing, first med first line medication for status epilepticus is 242 00:15:46.200 --> 00:15:50.519 going to be your benzo diazepines. So if you don't remember anything else for 243 00:15:50.600 --> 00:15:54.679 status, remember benzos. They're your main treatment and they're the best treatment because 244 00:15:54.679 --> 00:15:58.639 of the rapid on set. The three most commonly used is going to be 245 00:15:58.720 --> 00:16:03.679 diazepam, lorazepam, and medazzo lamb. Lurazepam is usually preferred for the IV 246 00:16:03.840 --> 00:16:07.320 route. So with benzos, you're going to give them their first dose when 247 00:16:07.360 --> 00:16:11.200 they're in status epilepticus and then reassess in about five to ten minutes. If 248 00:16:11.200 --> 00:16:14.440 they're still seizing at this point, you hit them with another round of benzos, 249 00:16:14.679 --> 00:16:17.559 and then if they're still seizing at this point, in addition to getting 250 00:16:17.559 --> 00:16:21.000 a neuroconsolate in EG, you're going to ramp up the meads and then next 251 00:16:21.000 --> 00:16:23.799 in line. There are some options, but second line will generally be with 252 00:16:23.919 --> 00:16:27.320 a fenny toone, so phos fenny tone, fenny tone. That's your second 253 00:16:27.399 --> 00:16:30.960 line for status epilepticus. Again, there are some other options. Valpro eight 254 00:16:32.519 --> 00:16:37.720 levitoractam, which is capra but generally for exams. For exam purposes, I 255 00:16:37.759 --> 00:16:41.240 would remember the fenny tones as your second line and then third line. If 256 00:16:41.279 --> 00:16:47.039 they're still seizing at this point, after you've given their fenny tones, they 257 00:16:47.080 --> 00:16:48.840 need to be intubated. They're going to be on mechanical ventilation. And as 258 00:16:48.840 --> 00:16:52.120 far as treatment, you do have some options, but pental barbital is the 259 00:16:52.159 --> 00:16:56.720 one you'll usually see tested on for your third line. It's really like your 260 00:16:56.799 --> 00:17:00.240 last option. Their brain is cooking, you need something. That's when you 261 00:17:00.279 --> 00:17:04.599 use pental barbital. Some guidelines will suggest propofol continuous infusion with Medazzo lamp. 262 00:17:04.720 --> 00:17:08.119 At this point you're basically putting them into a drug induced coma as save them. 263 00:17:08.279 --> 00:17:11.880 But again for the boards, I would tell you to focus on your 264 00:17:11.920 --> 00:17:15.839 third or your last line treatment as pental barbital. That's normally what was tested 265 00:17:15.880 --> 00:17:18.400 on, That's what I was tested on. And just an fyi, you 266 00:17:18.440 --> 00:17:23.119 may have heard of phenobarbital being used for status, but pental barbital has replaced 267 00:17:23.160 --> 00:17:26.519 it due to being more efficacious. It has better brain penetration and a shorter 268 00:17:26.559 --> 00:17:30.880 half life. So let's go over that. So for status epilepticus, you 269 00:17:30.920 --> 00:17:34.519 need to remember three lines of medications. You need to remember your benzos as 270 00:17:34.559 --> 00:17:37.480 your first and that's what I would really focus on. If you don't remember, 271 00:17:37.519 --> 00:17:41.000 If you don't want to remember all three, remember benzos. That's likely 272 00:17:41.000 --> 00:17:44.039 what you'll be tested on because your first line, there's not a lot of 273 00:17:44.079 --> 00:17:47.480 options. It's really just benzos. Like that's what everybody gets with status. 274 00:17:47.559 --> 00:17:48.599 So if you want to remember one thing, remember benzos. But if you 275 00:17:48.640 --> 00:17:52.559 want to remember all three, I do have your way for you to remember 276 00:17:52.599 --> 00:17:55.839 that. So did you want to think of when you're thinking of status epilepticus 277 00:17:56.160 --> 00:17:59.000 is as soon as you see status epilepticus, you want to think of a 278 00:17:59.039 --> 00:18:03.480 guy named Ben who update his tetanus status. So think of this sentence when 279 00:18:03.480 --> 00:18:07.480 you see status epilepticus, think of this. He had to update his tetanus 280 00:18:07.599 --> 00:18:12.640 status when Ben caught his toe in some barbed wire, so status epilepticus. 281 00:18:12.640 --> 00:18:18.160 He had to update his tetanus status when Ben caught his toe in some barbed 282 00:18:18.160 --> 00:18:21.599 wire. So what that stands for as he had to update his tetanus status, 283 00:18:21.599 --> 00:18:26.599 that helps you remember status epilepticus. When Ben Ben stands for benzodiazepines. 284 00:18:26.640 --> 00:18:30.839 Remember that's the first word in this sentence or the first part of this sentence, 285 00:18:30.839 --> 00:18:33.359 and that's your first line treatment. Caught his toe in t o i 286 00:18:33.599 --> 00:18:38.079 n because that's the part of the word fenny toin or foss fenny toen. 287 00:18:38.400 --> 00:18:42.519 So caught his toein. That helps you remember your second line fenny toen some 288 00:18:42.759 --> 00:18:48.920 barbed wire. That helps you remember pentobarbital. So again remember status epilepticus, 289 00:18:48.960 --> 00:18:52.319 first, second and third line meds. He had updated his tetanus status status 290 00:18:52.319 --> 00:18:57.880 epilepticus when ben first line benzodiazepines caught his toe in. Second line fennyten some 291 00:18:59.000 --> 00:19:02.920 barbed wire line is going to be your pental barbital and that's your treatment regimen 292 00:19:02.960 --> 00:19:07.119 for status epilepticus. Now with the rest of the meds, again, you're 293 00:19:07.240 --> 00:19:11.039 likely not going to be asked to pick the best men because there's really not 294 00:19:11.160 --> 00:19:15.359 one. With some exceptions I'll go over it's basically really just considering the contraindications 295 00:19:15.400 --> 00:19:18.640 for the meds, the cost its, ceterup. This is really individualized and 296 00:19:18.640 --> 00:19:21.559 really it's going to be up to a neurologist to decide this. But let's 297 00:19:21.559 --> 00:19:23.119 go over some of the more common meds go over a few pneumonics and things 298 00:19:23.160 --> 00:19:26.880 you should know for each. So I'm going to focus on the medications that 299 00:19:26.920 --> 00:19:29.079 I always tested on, the ones that always seem to come up. So 300 00:19:29.079 --> 00:19:33.279 the first one you need to know carbon maazopine. Carbon mazopine is a good 301 00:19:33.279 --> 00:19:37.119 med for both focal and generalized seizures, can be it can cause Stevens Johnson 302 00:19:37.200 --> 00:19:41.240 syndrome. Like almost all anti eleptic meds. I have a way for you 303 00:19:41.240 --> 00:19:44.880 to remember all those at the end, But the indications that you need to 304 00:19:45.000 --> 00:19:49.559 know for carbon maazepine, the first line that it's for is trigeminal neuralgia. 305 00:19:49.640 --> 00:19:53.200 It's a first line med for trigeminal neuralgis. Remember that about carbon maazepine. 306 00:19:53.359 --> 00:19:56.759 I said generally not first line meds for seizures, but that's not a seizure, 307 00:19:56.799 --> 00:20:00.119 it's trigeminal neuralgia. So if you know car amazopine is first line for 308 00:20:00.160 --> 00:20:03.359 trigeminal neuralgia, that's an important thing to remember. Second thing I would know 309 00:20:03.400 --> 00:20:07.279 for carbon mazopine is it's MOA and it blocks sodium channels. And then the 310 00:20:07.319 --> 00:20:11.640 third thing I would be aware of for carbon mazopine is one of the higher 311 00:20:11.680 --> 00:20:15.519 yield ADRs, and that's that it increases your LFTs. It's hepadotoxic. So 312 00:20:15.559 --> 00:20:21.279 again the three things for carbon maazepine. Remember it's first line medication for trigeminal 313 00:20:21.359 --> 00:20:25.039 neuralgia. Second thing to know it blocks sodium channels. And third is that 314 00:20:25.079 --> 00:20:29.880 it increases your LFT's your liver function test. It's apadotoxic. So the way 315 00:20:29.880 --> 00:20:34.319 that you remember those three things is as soon as you see carb amazepine carbamazepine, 316 00:20:34.960 --> 00:20:38.839 think of some salty carbs. So salty carbs like fries, and I 317 00:20:38.839 --> 00:20:44.599 want you to remember the sentence lift up some salty carbs and chew on them 318 00:20:44.680 --> 00:20:48.400 until your cheeks hurt. So as soon as you see carbamazepine, think of 319 00:20:48.440 --> 00:20:52.359 salty carbs, think of the sentence, lift up some salty carbs and chew 320 00:20:52.400 --> 00:20:55.960 on them till your cheeks hurt. So what that stands for lift up is 321 00:20:56.119 --> 00:21:00.160 LFT up because remember your LFTs go up, So lift up LFT up helps 322 00:21:00.160 --> 00:21:07.240 you remember it's apatotoxic. LFTs go up some salty carbs salty because that helps 323 00:21:07.240 --> 00:21:11.640 you remember it block sodium channel. Carbs is carbon maazopine and chewing them until 324 00:21:11.680 --> 00:21:15.279 your cheeks hurt. Your cheeks are hurting because remember this patient has trigeminal arauga 325 00:21:15.559 --> 00:21:18.960 and carbon mazopine is first line for trigeminal neralga. I remember you have that 326 00:21:19.000 --> 00:21:22.279 pain in the face from the nerves being affected. So again, carbon mazopine. 327 00:21:22.319 --> 00:21:26.480 Think of salty carbs. Lift up some salty carbs and chewing them till 328 00:21:26.519 --> 00:21:30.240 your cheeks hurt. Lift up your LFTs. Go up salty carbs because it 329 00:21:30.319 --> 00:21:33.240 blocks sodium channels and chewing them till your cheeks hurt. First line med for 330 00:21:33.319 --> 00:21:36.359 trigeminal nerauja. That's how you remember what you need to know for carbon maazopine. 331 00:21:36.640 --> 00:21:40.680 Moving on to valproic acid also known as valproe. So, this is 332 00:21:40.720 --> 00:21:45.200 a broad spectrum anti elliptic medication, very commonly used. It is a very 333 00:21:45.200 --> 00:21:48.799 good med It's really effective for both focal and generalized seizures. I know, 334 00:21:48.839 --> 00:21:51.920 I said, there's not really any first line seizure meds outside of the exceptions 335 00:21:51.920 --> 00:21:55.880 we talked about, but in some literature you will see this being used as 336 00:21:55.960 --> 00:22:00.799 first line for juvenile myoclonic epilepsy. Also, as we went over before, 337 00:22:00.880 --> 00:22:03.359 valproic acid can be used as a second line for apps on seizures. All 338 00:22:03.400 --> 00:22:07.799 just really FYI. The stuff generally is not going to be tested on. 339 00:22:07.880 --> 00:22:11.160 It's more again for neuro to decide the are the things that you need to 340 00:22:11.160 --> 00:22:14.119 know for valprooc acid are really about the adverse drug reactions. This is the 341 00:22:14.119 --> 00:22:17.279 important stuff. There's a few key things that you need to know about it. 342 00:22:17.319 --> 00:22:18.920 So what you're going to be tested on, these are the ones that 343 00:22:18.920 --> 00:22:23.319 I would focus on. First, valpro gacid is toteratogenic. Now, most 344 00:22:23.359 --> 00:22:30.119 anti elliptic anti elliptic medications are territogenic to an extent, but valproic acid by 345 00:22:30.440 --> 00:22:37.279 far is the worst and associated with the highest rate of triritogenicity of all marketed 346 00:22:37.319 --> 00:22:41.039 anti seizure medications. And for that reason, that's the one that they're going 347 00:22:41.079 --> 00:22:42.640 to test you on. They're going to give you a pregnant patient, ask 348 00:22:42.680 --> 00:22:45.000 which mad you should avoid in this patient. It's going to be valpro it 349 00:22:45.279 --> 00:22:49.039 So remember turritogenic, the worst of all the other anti seizure medications. You 350 00:22:49.039 --> 00:22:53.039 need to know that second thing. Pancreatitis In real life, it's not that 351 00:22:53.119 --> 00:22:56.680 common, but for some reason it's always seems to get tested on, So 352 00:22:56.759 --> 00:23:00.279 remember a Q Pancreatitis is a possible complication of proetherapy. The third thing you 353 00:23:00.319 --> 00:23:06.000 need to know a patotoxic so acute padle cellular injury can occur in valproa. 354 00:23:06.240 --> 00:23:10.279 This is usually within the first six months of starting this medication. Some cases 355 00:23:10.359 --> 00:23:12.720 can actually be associated with fulminate liver failure in death, so definitely know that 356 00:23:12.759 --> 00:23:17.799 too. So three things you need to remember for valproic acid. Three things 357 00:23:17.799 --> 00:23:22.279 that are generally tested on. That's pancreatitis, patotoxicity, and toteratogenic. How 358 00:23:22.319 --> 00:23:27.319 you remember that is valproic acid valproic acid VPA. The V stands for vertical 359 00:23:27.319 --> 00:23:32.480 transmission. This helps remember the toteratogenic effects of the med. I know vertical 360 00:23:32.480 --> 00:23:36.519 transmission generally first to a pathogen going from the mother to the baby, but 361 00:23:36.599 --> 00:23:37.880 in this case it's going to help you remember the med taken by the mother 362 00:23:37.880 --> 00:23:41.880 affects the baby. So again not exactly what a vertical transmission means, but 363 00:23:41.960 --> 00:23:45.599 whatever gets your mind to helping you remember the toteratogenicity will help you. So 364 00:23:45.759 --> 00:23:51.279 V vertical transmission helps you remember this is the worst med for pregnant patients. 365 00:23:51.720 --> 00:23:56.519 Second thing VPA, the p stands for pancreatitis, and then the A stands 366 00:23:56.519 --> 00:24:00.640 for acute padle cellular injury. So again, valproic acid VP a vertical transmission 367 00:24:00.680 --> 00:24:07.319 aka tatogenic p pancreatitis a acute hepato cellular injury. Moving on to fenny toin. 368 00:24:07.599 --> 00:24:11.759 So ifenny toe's been around since the nineteen thirties, we're still using it 369 00:24:11.799 --> 00:24:15.680 today. It's a good men for focal and generalized seizures. It's good for 370 00:24:15.839 --> 00:24:19.839 statocepilepticus as we know, it's second line after benzos. There's a laundry list 371 00:24:19.880 --> 00:24:23.200 of adverse drug reactions from fenny toin, but the important ones, the main 372 00:24:23.240 --> 00:24:27.160 systemic side effects that you need to remember are one hersotism, which you remember. 373 00:24:27.200 --> 00:24:33.200 Herstotism is an excessive hair growth in women. Two gingerable hypertrophe which is 374 00:24:33.200 --> 00:24:37.880 an abnormal overgrowth of gingerable tissues. And three folic acid depletion. It inhibits 375 00:24:37.880 --> 00:24:41.359 folic acid absorption. The other thing too, which again i'll go over at 376 00:24:41.400 --> 00:24:42.319 the end a way for you to remember this, but it can also cause 377 00:24:42.319 --> 00:24:47.079 Stephen Johnson's syndrome. So fenny toin what I want you to think of when 378 00:24:47.079 --> 00:24:51.119 you think of fenny toin is a toe in your mouth. So fenny toen, 379 00:24:51.440 --> 00:24:52.599 think of a toe in your mouth, and I want you to think 380 00:24:52.599 --> 00:24:56.960 of this sentence. If you put a hairy toe in your mouth and lick 381 00:24:56.039 --> 00:25:00.359 it, you'll get gingervitis. If you put hairy toe in your mouth and 382 00:25:00.440 --> 00:25:03.400 lick it, you'll get gingivitis. That helps you remember the three things that 383 00:25:03.440 --> 00:25:07.400 you need to know. So if you put a Harry, Harry helps you 384 00:25:07.400 --> 00:25:12.400 remember hersutism toein obviously that's from fenny toen and lick it, lic lick it. 385 00:25:12.960 --> 00:25:18.400 That helps you remember full lick acid depletion. So Harry hersutism toein fenny 386 00:25:18.400 --> 00:25:23.079 toin, lick it full lick acid depletion. And then and then you'll get 387 00:25:23.160 --> 00:25:27.039 gingervitis. That helps you remember of the gingerbal hypertrophe. So again you've put 388 00:25:27.039 --> 00:25:30.839 a hairy toe in your mouth and lick it, you'll get gingervitis. Hairry 389 00:25:30.880 --> 00:25:36.200 hersutism toin, fenny toin, lick it full like acid depletion and gingervitis. 390 00:25:36.240 --> 00:25:38.839 That would be gingerbal hypertrophe. And that's fenny toine. Okay, So a 391 00:25:38.839 --> 00:25:44.240 few other ones that I just wanted to mention. You know, fosuximide we 392 00:25:44.240 --> 00:25:47.720 already went over. Just know it does block calcium channels, that's its MOA. 393 00:25:47.920 --> 00:25:51.240 And then of course you know that it's the first line for absince seizures. 394 00:25:51.279 --> 00:25:53.599 Really that's the only use for this drug. Actually, it's a really 395 00:25:53.720 --> 00:25:59.799 narrow spectrum medication. So remember first line for absince seizures. I keep repeating 396 00:25:59.799 --> 00:26:02.599 that because you're gonna get a question and it, I promise you. And 397 00:26:02.640 --> 00:26:06.039 then of course you remember that because you know when you're absent into the ether 398 00:26:06.240 --> 00:26:08.680 you will vanish. And then also causes Stephen Johnson syndrome surprise, surprise, 399 00:26:10.160 --> 00:26:12.319 pentobarbital. The main thing that you need to know for this, really the 400 00:26:12.319 --> 00:26:15.880 only thing that you need to know this for this, Like we went over 401 00:26:15.920 --> 00:26:21.119 before, it's last line treatment for status eplepticus after Fanny toe Leavitt Taractam, 402 00:26:21.240 --> 00:26:26.119 which is keepra. It's another broad spectrum anti eleptic medication, commonly used because 403 00:26:26.160 --> 00:26:29.440 its side effect profile is pretty favorable compared to some of the other options, 404 00:26:29.720 --> 00:26:32.640 doesn't have as many adverse drug reactions compared to some of the other mets we 405 00:26:32.720 --> 00:26:37.519 went over. There's some other anti elliptic medications. Lamotrigene, TOPIRAMATEE. There's 406 00:26:37.559 --> 00:26:41.160 just not a lot of high old in photo no for those. And I 407 00:26:41.200 --> 00:26:44.599 didn't cover every anti elliptic medication. There's over twenty five of them, so 408 00:26:44.720 --> 00:26:47.319 that would be crazy to cover all of them. But again I did focus 409 00:26:47.400 --> 00:26:49.240 on the high old ones, the ones that have unique ADRs, the ones 410 00:26:49.279 --> 00:26:52.359 that are often tested on. So know those ones that I went over, 411 00:26:52.519 --> 00:26:56.519 remember those nemonics. One last little tip, not so crucial enough for seizures 412 00:26:56.559 --> 00:27:00.400 in general, but good overall knowledge for the pants for some thing that does 413 00:27:00.480 --> 00:27:03.200 come up from time to time. So, most anti elliptic meds can cause 414 00:27:03.240 --> 00:27:07.880 Stephen Johnson syndrome. As we went over Steven Johnson syndrome. If you're not 415 00:27:07.000 --> 00:27:12.240 familiar with it, it's a severe mucocutaneous reaction. It's commonly triggered by medications. 416 00:27:12.519 --> 00:27:17.160 It can cause necrosis, detachment of the epidermist. It's pretty serious, 417 00:27:18.039 --> 00:27:21.839 so you need to know the meds that can cause it. Again, most 418 00:27:21.880 --> 00:27:25.359 anti elliptic mads can cause this, but there's some non anti elliptic meds that 419 00:27:25.400 --> 00:27:27.319 can cause it too. It's fairly important to know of these meds. Again, 420 00:27:27.359 --> 00:27:30.599 you're likely going to get a question on this at some point. So 421 00:27:30.680 --> 00:27:33.519 the way that you remember them, that you'll remember the heavy hitters, the 422 00:27:33.559 --> 00:27:37.720 main meds it will cause this are by remembering that Stephen Johnson syndrome. I 423 00:27:37.799 --> 00:27:42.960 want you to think of Steve Jobs created Apple PCs. So Stephen Johnson, 424 00:27:44.319 --> 00:27:47.480 the first few letters of that is also the first few letters of Steve Jobs. 425 00:27:47.680 --> 00:27:49.160 So as soon as you see Stephen Johnson syndrome, ods you to think 426 00:27:49.160 --> 00:27:53.079 of Steve Jobs and what did Steve Jobs do? He created Apple PCs. 427 00:27:53.359 --> 00:28:00.440 So Stephen Johnson syndrome, think Steve Jobs created Apple PC's and Apple PC stands 428 00:28:00.480 --> 00:28:04.759 for all of the main meds that cause Steven Johnson syndrome. So A allopurinol 429 00:28:06.200 --> 00:28:11.200 P fenny tooin P, phenobarbital, al lamotrigene, e ethosuximide, P, 430 00:28:11.480 --> 00:28:15.920 penicillans, C, carbon, mazopines, and s sulfonamides. So again, 431 00:28:17.039 --> 00:28:23.200 Steve Jobs created Apple PC's alipuranol fenny tooin phenobarbital, lamotrigene, ethosuximide, penicillans, 432 00:28:23.440 --> 00:28:26.640 carbon, mazopine, and sulfonamides. That's how you remember you're Stephen Johnson 433 00:28:26.680 --> 00:28:32.440 synder medications. Let's do five quick high old questions and then we will wrap 434 00:28:32.519 --> 00:28:34.680 this up. Question one, a nine year old male presents to the office 435 00:28:34.720 --> 00:28:38.480 accompanied by his mother. His mother states that he the boy has had frequent 436 00:28:38.519 --> 00:28:42.119 episodes where he will zone out and stare off into space for a few seconds, 437 00:28:42.400 --> 00:28:47.200 multiple times per day. The mother states the boys unresponsive to her voice 438 00:28:47.279 --> 00:28:51.599 or tactile stimulation during the episodes. The patient has an EEG performed during one 439 00:28:51.599 --> 00:28:56.359 of the episodes in the office which displays a generalized three hurts, spike and 440 00:28:56.480 --> 00:29:00.559 wave appearance. What is the first line medication for the likely diagnosed in this 441 00:29:00.720 --> 00:29:03.559 patient? So we know that is going to be ethosuximide. So this patient 442 00:29:03.599 --> 00:29:07.720 has classic findings of an APPS on seizure, so sudden impairment of consciousness lasting 443 00:29:07.839 --> 00:29:11.480 seconds, occurring multiple times per day. In addition, we have the classic 444 00:29:11.519 --> 00:29:15.000 findings on the eg that three hurt spike and wave pattern. We know first 445 00:29:15.079 --> 00:29:19.480 line med for APPS on seizures is ethosuximide because you remember, if you're absent 446 00:29:19.640 --> 00:29:23.799 into the ether, you will vanish. Question two. Sixty four year old 447 00:29:23.799 --> 00:29:27.680 homeless man is brought into the emergency room by fire rescue. The paramedic state 448 00:29:27.720 --> 00:29:30.680 he has been actively seizing for the entire ride over, which has been over 449 00:29:30.799 --> 00:29:34.720 fifteen minutes. On physical exam, you note a rhythmic jerking of the bilateral 450 00:29:34.799 --> 00:29:38.440 extremities. What is the first line medication class that should be initiated in this 451 00:29:38.599 --> 00:29:42.599 patient? So that is going to be benzodiazepines. So this is status epilepticus, 452 00:29:42.920 --> 00:29:47.480 which is defined as either a single seizure that lasts over five minutes or 453 00:29:47.640 --> 00:29:51.119 if they have more than one seizure without recovery between each episode. This patient 454 00:29:51.200 --> 00:29:55.839 meets that criteria because we see he's been actively seizing over fifteen minutes. So 455 00:29:55.960 --> 00:29:59.359 we know the first line med for status epilepticus is benzos, So that's going 456 00:29:59.400 --> 00:30:03.079 to be diazepe and lorazepam, medazolam if that doesn't work. Next line we 457 00:30:03.160 --> 00:30:07.799 know our if any tones, and then finally pental barbital. Remember he had 458 00:30:07.839 --> 00:30:12.039 to update his tetanus status when ben caught his toin some barbed wire. Question 459 00:30:12.200 --> 00:30:18.839 three, which type of generalized seizure is described by sudden muscle stiffening often associated 460 00:30:18.880 --> 00:30:22.880 with impaired consciousness. So sudden muscle stiffening, remember that is a tonic seizure. 461 00:30:23.160 --> 00:30:26.400 Remember a gin and tonic is a stiff drink that helps you remember a 462 00:30:26.480 --> 00:30:32.319 tonic seizure is a seizure evolving stiffness and rigidity of muscles. Question four, 463 00:30:32.599 --> 00:30:36.839 which anti elliptic medication works by blocking sodium channels? And his first line for 464 00:30:36.960 --> 00:30:42.279 trigeminal neuralgia. So again, remember that is carbamazepine. Because remember carbamazepine, 465 00:30:42.640 --> 00:30:47.720 lift up some salty carbs and chewing them till your cheeks hurt. Remember cheeks 466 00:30:47.759 --> 00:30:51.640 hurt, that's trigeminal neuralgia. This is your first line treatment for trigeminal neuralgia. 467 00:30:52.119 --> 00:30:56.039 Question five, what is the most common type of generalized seizure? So 468 00:30:56.119 --> 00:30:59.200 the most common type of generalize seizure is going to be your toniclonic, your 469 00:30:59.240 --> 00:31:02.759 grandmall seizure. So tonic clonic again, starts with your tonic phase. All 470 00:31:02.759 --> 00:31:06.480 the muscles become stiff after a minute to the chronic phase begins where the muscles 471 00:31:06.559 --> 00:31:08.440 begin to jerk and twitch for an additional one to two minutes. All right, 472 00:31:08.480 --> 00:31:11.720 that is seizures. Thank you so much for listening, and thank you 473 00:31:11.759 --> 00:31:14.960 again so much for the support and good luck in PA school. Good luck 474 00:31:15.000 --> 00:31:15.720 and your pants your panory. You're rs.