S1E43 Seizures

All right, so moving along with the neurosection, we're going to talk about
seizures today. Decent amount of material for you to know. I do have
some mnemonics in there to help you remember the important stuff. So thank you
as always for the support, the really nice comments. I do appreciate every
single comment and everything. I just really appreciate the support, So thank you
so much for that. Let's talk about seizures. So first let's go over
the definition. The official definition would be a sudden change in behavior caused by
electrical hypersynchronization of neuronal networks in the cerebral cortex. So that's a lot of
different words. Let's actually talk about what that means. So neurons are synchronously
active, so all the neurons they're firing together. They're not supposed to be.
Whether this is caused by too much excitation, caused by problems with the
NMDA receptors, too little inhibition with defective GABA receptors, the effect is the
same. You have neurons firing inappropriately NonStop, which causes a number of clinical
manifestations. Will go over. Now, there's some causes of seizures that you
should be aware of. I don't expect you to re memorize all of these.
But there is anemonic that I've come across that's not my own, but
it's called vitamins, and it stands for some of the more common causes of
your provoked seizure. So vitamin stands for v vascular, so vascular malformation,
stroke, I stands for infections, meningitis, and cephalalitis. T stands for
trauma, so like a traumatic brain injury, a autoimmune think lupus. M
stands for metabolic, so I think low blood sugar. Most low electrolytes can
cause seizures, so hypocalcemia hyponatremium. I stands for ingestion, so whether it's
ingestion of toxins like drugs which lead to the seizure, or withdrawal from ingestion
of certain toxins like alcohol withdrawal which can lead to seizures. ND stands for
neoplasms like brain tumor. And then the S stands for the second letter in
psych so psychogenic. So non epileptic seizures think conversion disorder. Now let's talk
about the different types of seizures. The first thing that I wanted to go
over is the definition of epilepsy because we're going to be thrown around that word
a lot. So to make the diagnosis of epilepsy, there's some criteria to
meat and most cases, though epilepsy just means you've had recurrent seizures, but
the official diagnostic criteria is either two or more unprovoked seizures occurring more than twenty
four hours apart. Unprovoked means it wasn't caused by one of the vitamins we
just went over, so it wasn't a low blood sugar or an infection that
caused it, etc. Another criteria would be one unprovoked seizure and a high
risk of recurrence. So a patient that only had one seizure but has a
high risk of second seizure can be diagnosed with epilepsy and high risk meaning they
had a stroke, traumatic brain injury, brain tumor things that are going to
put them on a high risk for a second one. And then the third
one is kind of nonspecific identifiable epilepsy syndrome, So this is either genetic or
idiopathic epilepsy. So that's epilepsy. Now let's talk about different specific types of
seizures. So most seizures can be categorized by either focal or generalized depending on
where they affect. So when just one hemisphere of the brain is affected,
just half the brain, or even just one low this is called a focal
seizure, and then in generalize seizures both sides of the brain are affected simultaneously.
Focal seizures can be categorized further depending on whether or not consciousness is altered
during the event, so you have focal seizures with retained awareness. These used
to be called simple partial seizures. He may still hear them, being called
that the presentation will be unique in each patient with this type because it really
all depends on the part of the cortex that's affected at the onset of the
seizure. So if it affects the occipital cortex, it may result in flashing
lights. The frontal lobe can cause sudden speech difficulties. There may be changes
in hearing and taste. It's possible to have involuntary movements or jerking movements the
key though, as the name suggests, generally they will retain awareness or their
consciousness during the episode, so they should have retained awareness during this type of
focal seizure. The other type of focal seizure is impaired awareness, used to
be called complex partial. So during a typical focal seizure with impaired awareness,
the patients may appear to be awake, but they're not going to respond to
normal and struggles or questions. They may stare into space, they may remain
motionless, engage in repetitive behaviors. These are called automatisms. They can include
facial grimacing, lip smacking, etc. So their behavior is altered in some
way. And then afterwards, most of the time these patients are going to
enter what's called the post Ichtl phase and during this time they may have confusion
headache for up to several hours. All right, so let's talk about generalized
seizures now. So if generalized seizures, again, both hemispheres of the brain
are going to be affected and in most cases these types of seizures will involve
some degree of altered consciousness. Not always but most cases. So there's different
types of generalized seizures. The most common, though by far the most common,
type of generalized seizure is going to be one called a tonic clonic,
also known as a grand mall seizure. So most common generalize seizure. It's
basically what everyone thinks of when they think of the classic seizure presentation. So
let's go over what that involves. So, tonic clonic grandmall seizures, what
does this mean? So first let's understand what the terms tonic and chlonic mean.
Tonic means rigidity or a sudden muscle stiffening. The muscles get stiff.
Sometimes they can stay contracted or stiff up to a minute or two during this
tonic phase. And then the second part of this is the klonic phase,
which means rhythmic jerking muscle contractions. It's usually going to be of the arms,
neck, and face. So a tonic chronic seizure, you put those
together, usually begins with an abrupt loss of consciousness. This is followed by
the tonic phase where all the muscles become stiff. Then after a minute or
so, the muscles begin to jerk twitch for an additional one to two minutes,
and that's your klonic phase. And this is normally followed by a post
Ichtl phase. All right, so a tonic chronic that's the big one you
need to focus on. Let's talk about some other types of generalize seizures that
may come up. So myoclonic. Myoclonic is normally going to involve either a
single muscle, sometimes a group of muscles, and it's just a brief contraction,
like a just a quick jerking motion, a really quick contraction of a
muscle, then it stops. Most commonly it's going to involve the arms,
and consciousness is usually not impaired in this type klonic just like we went over
in time klonic seizures. Chlonic portion causes rhythmic jerking and muscle contractions that usually
involve the arms, neck, and face. Tonic, just like we just
went over, usually a sudden muscle stiffening, so the muscles get stiff,
often associated with a loss of consciousness. The way that I used to remember
what tonic meant, because there's so many different names, sometimes you can get
confused. So as soon as I see tonic seizure, I think of a
gin and tonic, and the gin in tonic is a stiff drink. So
as soon as you see tonic, think of a gin and tonic, which
you know as a stiff drink, and then it helps you remember tonic seizures
cause muscle stiffening. And then the next type is called an atonic seizure.
So if you can remember what a tonic seizure is, you can remember what
an atonic seizure is because it's the exact opposite. So atonic means the muscles
basically turned to jello, so the opposite of stiffening like in tonic. So
these individuals with atonic seizures will have a sudden loss of control of the muscles.
Commonly, this is going to involve the legs and it's going to cause
these patients just to collapse. They'll be conscious in most cases, they'll just
lose control of their muscles and just drop to the ground. And that's why
you sometimes hear these being called drop seizures because their legs turn to jello and
they just drop to the ground. So if you can remember what tonic is,
you can remember what a tonic is, and you can knock out two
right there. And then the last one is something known as absence seizures or
absent seizures. I think the correct way is absons, though these used to
be called petite mall seizures. Usually you're going to see these in children.
And what happens in these children is they'll be in class, they'll be at
home, they're doing fine, no issues, and then all of a sudden,
they'll just be staring. They'll have the state of impaired consciousness. They
won't respond to any verbal or tactile stimuli. During these episodes. They may
also have eyeblinking and lip smacking. This can occur hundreds of times per day,
and typically each episode will last between five to ten seconds. A lot
of times it's misdiagnosed as ADHD. So again absence seizure, no loss in
muscle tone, but impaired consciousness for just brief periods. No Abson seizures.
Very well, You're going to be tested on this because it has a unique
presentation and has a specific first line med which will go over and like all
unique things with specific first line meds, you're always going to get tested on
them. So make sure you know abs on seizures. I have a little
mneumonic for you to remember the treatment too when we go over that. And
then the last type of seizure or not so much a specific type of seizure,
more just a seizure that lasts two damn long is status epilepticus. So
the official diagnosis or the official definition of status epilepticus is an unremitting generalized convulsive
seizure lasting longer than five minutes, or multiple bilateral convulsive seizures without a return
to baseline level of consciousness. So either this patient has a single seizure the
lasts over five minutes, or they have more than one seizure without recovery between
each episode. Some medical neurological emergency neurons are firing NonStop, they're essentially frying
their brain. Have to board the seizure quickly, and these patients are going
to need prompt treatment, and we'll go over the treatment protocol in a minute.
This is another one that you really need to know now diagnosis. So
with diagnosis, you're obviously going to start with a very thorough history. It
a lot of times this will be obtained from a friend or family member that
witnessed the seizure. You'll need to find out was there any trauma, is
there any drug or alcohol use. Most patients with epilepsy, though, are
going to have a fairly unremarkable clinical history, and then of course you want
to have a very thoroughphysical exam, including a neuroexam, and then let's talk
about your initial lab work. So your initial laboratory tests. You're definitely gonna
get a rapid blood glucose. You want to make sure this isn't hypoglycemia.
You're going to get a CBC. CBC you're looking for signs of infection.
You want to get a CMP, and the CMP you're checking electrolytes. You
want to make sure this wasn't from hypocalcemia hyponatremia. You're also checking your renal
function with this your LFTs, and then you want to do your analysis in
a toxicology screen. So a lot of different things basically to search for those
vitamins we went over earlier. You're looking for a potentially reversible cause, so
be aware of those different lab tests. I wouldn't say to memorize all of
them, just have a general overview. One lab though, that I do
want to go into a little bit more detail about is serum lactate. So
cerum lactate is a good lab to obtain in a patient who had an unwitness
transient loss of con bousness, so no one to say that, yeah,
they were seasoned convulsive flowling their arms, et cetera, that you suspect may
have had a seizure because a serum lactate, if it's elevated in the first
two hours after the event, this essentially confirms that it was a generalized seizure
rather than some other cause, just like a regular syncople episode or a psychogenic
non epileptic seizure. So another one that you may have you may hear of
is serum prolactin. It's another lab that you can use, but it's not
as sensitive or specific as a serum lactate and it's usually not recommended as part
of the routine eval. But cerum lactate is definitely an important one that you
should know. Neural imaging, so whether this is an MRI or CT in
a patient with their first seizure, you have to get some imaging of the
brain. You want to make sure there isn't any brain abnormalities intracranial neoplasma,
et cetera. MRI is going to be preferred, it's the better test,
but CT is another alternative. And then let's talk about our egs. So
once you've ruled out your vitamins, this isn't from you know, vascular stroke,
confection, meningitis and cephalitis, et cetera. You want to obtain an
EEG and electron cephalography. It's not one hundred percent sensitive, but if it
is abnormal, it can help support the diagnosis of an epileptic seizure, and
it can also help distinguish between generalized or focal seizures. General there's not a
lot to know about the specific findings for an EG except from one thing.
If you see an avignette they mention a three hurts, spike and wave pattern
right away, be thinking absent seizure. I wouldn't worry so much about why.
Just know if you see three hurts, spike and wave pattern a vignette,
the answer is absent seizure. As you're done, so remember that.
So if your diagnostic studies again, remember three things. Neuroimaging MRI I preferred
over CT, your labs, checking electrolytes, blood, glucose, etc.
And then an EEG. That's the three main things to focus on for diagnosis.
Let's talk about treatment now. So with anti elleptic medications, there's really
no first line meds quoted from up to date, no single anti seizure medication
is clearly the most effective or best tolerated. So in general they're not going
to list four or five different seizure meds and say which one would you pick.
There is some exceptions. I'm going to go over those, So this
isn't one hundred percent like an absence will go over. There is a first
line MEN obviously, and there's some other specific circumstances I'll go over. But
in general, there's really been a lot of studies and they don't really find
one seizure men to be better than another. Again, there are some exceptions.
The most important thing though about anti seizure medication is knowing specific adverse drug
reactions, so they could ask you something related to that. It's not so
much again about which med's going to work best to prevent the patient seizure,
but which med will be safest considering the patient's comorbidities and things like that.
Now, most patients with their first seizure, they're not going to require anti
elliptic medication. These patients that you're going to start on anti elliptic medications are
specific specific patients. So for instance, patient with two or more seizures,
because then by definition, these patients have epilepsy and each treatment or a patient
that you would start anti seizure medications with only one seizure their first seizure are
patients that have a high risk for a second. So again like we went
over before, they have a high risk finding like maybe a brain tumor,
they had a stroke, head trauma, abnormal neuroexam with focal findings, and
abnormal EEG. These are all high risk findings and if these patients it'd be
acceptable to start them on meds with just one seizure. Another situation where you'd
start a patient on anti seizure medications with just one seizure would be if they
wound up going into status epilepticus, because these patients are at very high risk
for a number of problems. So those are the patients you'll start most patients,
so with their first seizure, you're not going to start on anti seizure
medications. Just be aware of some of those circumstances where you would. So
let's first talk about two types of seizures where there is a specific first line
therapy, So there's a couple different meds that you need to know for these
and these different types of seizures are really the ones that you need to focus
on for your exam because these are likely where a lot of your questions will
come from when we're talking about medications. So the first one we need to
go over. It is probably the most important type of seizure for you to
know. Questions always seem to be asking about this, and that's absent seizures.
So for absent seizures, you have a first line medication you absolutely have
to know, and that's Etho sucks a mine. That's your first line med
Etho sucks, Etho sucks and mine, however you want to pronounce it.
That is your first line medication for absent seizures. Second line med would be
valpro eight. I normally don't recommend memorizing a second line med just because you
have so many medications memorize anyways. But the thing is that I was asked
in school, so I feel like you should probably know it because maybe it'll
come up for you too, And I do have a way for you to
remember both. So an absence seizures, your first line again, it's going
to be Etho sucksomides. Second line is going to be valpro eight. The
way that you remember that hopefully you've heard this expression. But there's an expression
that's known vanishing into the ether. And it's like when you're just gone,
you're absent, somebody like disappear. They vanished into the ether. So the
way that I remember absent seizures medication regimen is I remember if you're absent,
like absent seizure. If you're absent into the ether, you will vanish.
If you're absent, like in an absent seizure, into the ether, you
will vanish. And that sentence is in order because ether comes first and ether
is the first three letters in Etho sucks amine. So ether you will vanish
and then vanish. The second word is your second line med and that's valpro
eight, So that's va and vanish. That's your first couple of letters of
valpro eight. So if you're absent into the ether, you will vanish.
And that's how you remember your first and your second line meds for absent seizures.
Remember again Atho suximide, first line, Valpro eight, second line.
If you're absent into the ether, you will vanish. Then the second thing
that you really need to know a specific medication regiment is for status epilepticus.
Remember status epilepticus, a seizure, then I went on for two dam long.
So the first thing, first med first line medication for status epilepticus is
going to be your benzo diazepines. So if you don't remember anything else for
status, remember benzos. They're your main treatment and they're the best treatment because
of the rapid on set. The three most commonly used is going to be
diazepam, lorazepam, and medazzo lamb. Lurazepam is usually preferred for the IV
route. So with benzos, you're going to give them their first dose when
they're in status epilepticus and then reassess in about five to ten minutes. If
they're still seizing at this point, you hit them with another round of benzos,
and then if they're still seizing at this point, in addition to getting
a neuroconsolate in EG, you're going to ramp up the meads and then next
in line. There are some options, but second line will generally be with
a fenny toone, so phos fenny tone, fenny tone. That's your second
line for status epilepticus. Again, there are some other options. Valpro eight
levitoractam, which is capra but generally for exams. For exam purposes, I
would remember the fenny tones as your second line and then third line. If
they're still seizing at this point, after you've given their fenny tones, they
need to be intubated. They're going to be on mechanical ventilation. And as
far as treatment, you do have some options, but pental barbital is the
one you'll usually see tested on for your third line. It's really like your
last option. Their brain is cooking, you need something. That's when you
use pental barbital. Some guidelines will suggest propofol continuous infusion with Medazzo lamp.
At this point you're basically putting them into a drug induced coma as save them.
But again for the boards, I would tell you to focus on your
third or your last line treatment as pental barbital. That's normally what was tested
on, That's what I was tested on. And just an fyi, you
may have heard of phenobarbital being used for status, but pental barbital has replaced
it due to being more efficacious. It has better brain penetration and a shorter
half life. So let's go over that. So for status epilepticus, you
need to remember three lines of medications. You need to remember your benzos as
your first and that's what I would really focus on. If you don't remember,
If you don't want to remember all three, remember benzos. That's likely
what you'll be tested on because your first line, there's not a lot of
options. It's really just benzos. Like that's what everybody gets with status.
So if you want to remember one thing, remember benzos. But if you
want to remember all three, I do have your way for you to remember
that. So did you want to think of when you're thinking of status epilepticus
is as soon as you see status epilepticus, you want to think of a
guy named Ben who update his tetanus status. So think of this sentence when
you see status epilepticus, think of this. He had to update his tetanus
status when Ben caught his toe in some barbed wire, so status epilepticus.
He had to update his tetanus status when Ben caught his toe in some barbed
wire. So what that stands for as he had to update his tetanus status,
that helps you remember status epilepticus. When Ben Ben stands for benzodiazepines.
Remember that's the first word in this sentence or the first part of this sentence,
and that's your first line treatment. Caught his toe in t o i
n because that's the part of the word fenny toin or foss fenny toen.
So caught his toein. That helps you remember your second line fenny toen some
barbed wire. That helps you remember pentobarbital. So again remember status epilepticus,
first, second and third line meds. He had updated his tetanus status status
epilepticus when ben first line benzodiazepines caught his toe in. Second line fennyten some
barbed wire line is going to be your pental barbital and that's your treatment regimen
for status epilepticus. Now with the rest of the meds, again, you're
likely not going to be asked to pick the best men because there's really not
one. With some exceptions I'll go over it's basically really just considering the contraindications
for the meds, the cost its, ceterup. This is really individualized and
really it's going to be up to a neurologist to decide this. But let's
go over some of the more common meds go over a few pneumonics and things
you should know for each. So I'm going to focus on the medications that
I always tested on, the ones that always seem to come up. So
the first one you need to know carbon maazopine. Carbon mazopine is a good
med for both focal and generalized seizures, can be it can cause Stevens Johnson
syndrome. Like almost all anti eleptic meds. I have a way for you
to remember all those at the end, But the indications that you need to
know for carbon maazepine, the first line that it's for is trigeminal neuralgia.
It's a first line med for trigeminal neuralgis. Remember that about carbon maazepine.
I said generally not first line meds for seizures, but that's not a seizure,
it's trigeminal neuralgia. So if you know car amazopine is first line for
trigeminal neuralgia, that's an important thing to remember. Second thing I would know
for carbon mazopine is it's MOA and it blocks sodium channels. And then the
third thing I would be aware of for carbon mazopine is one of the higher
yield ADRs, and that's that it increases your LFTs. It's hepadotoxic. So
again the three things for carbon maazepine. Remember it's first line medication for trigeminal
neuralgia. Second thing to know it blocks sodium channels. And third is that
it increases your LFT's your liver function test. It's apadotoxic. So the way
that you remember those three things is as soon as you see carb amazepine carbamazepine,
think of some salty carbs. So salty carbs like fries, and I
want you to remember the sentence lift up some salty carbs and chew on them
until your cheeks hurt. So as soon as you see carbamazepine, think of
salty carbs, think of the sentence, lift up some salty carbs and chew
on them till your cheeks hurt. So what that stands for lift up is
LFT up because remember your LFTs go up, So lift up LFT up helps
you remember it's apatotoxic. LFTs go up some salty carbs salty because that helps
you remember it block sodium channel. Carbs is carbon maazopine and chewing them until
your cheeks hurt. Your cheeks are hurting because remember this patient has trigeminal arauga
and carbon mazopine is first line for trigeminal neralga. I remember you have that
pain in the face from the nerves being affected. So again, carbon mazopine.
Think of salty carbs. Lift up some salty carbs and chewing them till
your cheeks hurt. Lift up your LFTs. Go up salty carbs because it
blocks sodium channels and chewing them till your cheeks hurt. First line med for
trigeminal nerauja. That's how you remember what you need to know for carbon maazopine.
Moving on to valproic acid also known as valproe. So, this is
a broad spectrum anti elliptic medication, very commonly used. It is a very
good med It's really effective for both focal and generalized seizures. I know,
I said, there's not really any first line seizure meds outside of the exceptions
we talked about, but in some literature you will see this being used as
first line for juvenile myoclonic epilepsy. Also, as we went over before,
valproic acid can be used as a second line for apps on seizures. All
just really FYI. The stuff generally is not going to be tested on.
It's more again for neuro to decide the are the things that you need to
know for valprooc acid are really about the adverse drug reactions. This is the
important stuff. There's a few key things that you need to know about it.
So what you're going to be tested on, these are the ones that
I would focus on. First, valpro gacid is toteratogenic. Now, most
anti elliptic anti elliptic medications are territogenic to an extent, but valproic acid by
far is the worst and associated with the highest rate of triritogenicity of all marketed
anti seizure medications. And for that reason, that's the one that they're going
to test you on. They're going to give you a pregnant patient, ask
which mad you should avoid in this patient. It's going to be valpro it
So remember turritogenic, the worst of all the other anti seizure medications. You
need to know that second thing. Pancreatitis In real life, it's not that
common, but for some reason it's always seems to get tested on, So
remember a Q Pancreatitis is a possible complication of proetherapy. The third thing you
need to know a patotoxic so acute padle cellular injury can occur in valproa.
This is usually within the first six months of starting this medication. Some cases
can actually be associated with fulminate liver failure in death, so definitely know that
too. So three things you need to remember for valproic acid. Three things
that are generally tested on. That's pancreatitis, patotoxicity, and toteratogenic. How
you remember that is valproic acid valproic acid VPA. The V stands for vertical
transmission. This helps remember the toteratogenic effects of the med. I know vertical
transmission generally first to a pathogen going from the mother to the baby, but
in this case it's going to help you remember the med taken by the mother
affects the baby. So again not exactly what a vertical transmission means, but
whatever gets your mind to helping you remember the toteratogenicity will help you. So
V vertical transmission helps you remember this is the worst med for pregnant patients.
Second thing VPA, the p stands for pancreatitis, and then the A stands
for acute padle cellular injury. So again, valproic acid VP a vertical transmission
aka tatogenic p pancreatitis a acute hepato cellular injury. Moving on to fenny toin.
So ifenny toe's been around since the nineteen thirties, we're still using it
today. It's a good men for focal and generalized seizures. It's good for
statocepilepticus as we know, it's second line after benzos. There's a laundry list
of adverse drug reactions from fenny toin, but the important ones, the main
systemic side effects that you need to remember are one hersotism, which you remember.
Herstotism is an excessive hair growth in women. Two gingerable hypertrophe which is
an abnormal overgrowth of gingerable tissues. And three folic acid depletion. It inhibits
folic acid absorption. The other thing too, which again i'll go over at
the end a way for you to remember this, but it can also cause
Stephen Johnson's syndrome. So fenny toin what I want you to think of when
you think of fenny toin is a toe in your mouth. So fenny toen,
think of a toe in your mouth, and I want you to think
of this sentence. If you put a hairy toe in your mouth and lick
it, you'll get gingervitis. If you put hairy toe in your mouth and
lick it, you'll get gingivitis. That helps you remember the three things that
you need to know. So if you put a Harry, Harry helps you
remember hersutism toein obviously that's from fenny toen and lick it, lic lick it.
That helps you remember full lick acid depletion. So Harry hersutism toein fenny
toin, lick it full lick acid depletion. And then and then you'll get
gingervitis. That helps you remember of the gingerbal hypertrophe. So again you've put
a hairy toe in your mouth and lick it, you'll get gingervitis. Hairry
hersutism toin, fenny toin, lick it full like acid depletion and gingervitis.
That would be gingerbal hypertrophe. And that's fenny toine. Okay, So a
few other ones that I just wanted to mention. You know, fosuximide we
already went over. Just know it does block calcium channels, that's its MOA.
And then of course you know that it's the first line for absince seizures.
Really that's the only use for this drug. Actually, it's a really
narrow spectrum medication. So remember first line for absince seizures. I keep repeating
that because you're gonna get a question and it, I promise you. And
then of course you remember that because you know when you're absent into the ether
you will vanish. And then also causes Stephen Johnson syndrome surprise, surprise,
pentobarbital. The main thing that you need to know for this, really the
only thing that you need to know this for this, Like we went over
before, it's last line treatment for status eplepticus after Fanny toe Leavitt Taractam,
which is keepra. It's another broad spectrum anti eleptic medication, commonly used because
its side effect profile is pretty favorable compared to some of the other options,
doesn't have as many adverse drug reactions compared to some of the other mets we
went over. There's some other anti elliptic medications. Lamotrigene, TOPIRAMATEE. There's
just not a lot of high old in photo no for those. And I
didn't cover every anti elliptic medication. There's over twenty five of them, so
that would be crazy to cover all of them. But again I did focus
on the high old ones, the ones that have unique ADRs, the ones
that are often tested on. So know those ones that I went over,
remember those nemonics. One last little tip, not so crucial enough for seizures
in general, but good overall knowledge for the pants for some thing that does
come up from time to time. So, most anti elliptic meds can cause
Stephen Johnson syndrome. As we went over Steven Johnson syndrome. If you're not
familiar with it, it's a severe mucocutaneous reaction. It's commonly triggered by medications.
It can cause necrosis, detachment of the epidermist. It's pretty serious,
so you need to know the meds that can cause it. Again, most
anti elliptic mads can cause this, but there's some non anti elliptic meds that
can cause it too. It's fairly important to know of these meds. Again,
you're likely going to get a question on this at some point. So
the way that you remember them, that you'll remember the heavy hitters, the
main meds it will cause this are by remembering that Stephen Johnson syndrome. I
want you to think of Steve Jobs created Apple PCs. So Stephen Johnson,
the first few letters of that is also the first few letters of Steve Jobs.
So as soon as you see Stephen Johnson syndrome, ods you to think
of Steve Jobs and what did Steve Jobs do? He created Apple PCs.
So Stephen Johnson syndrome, think Steve Jobs created Apple PC's and Apple PC stands
for all of the main meds that cause Steven Johnson syndrome. So A allopurinol
P fenny tooin P, phenobarbital, al lamotrigene, e ethosuximide, P,
penicillans, C, carbon, mazopines, and s sulfonamides. So again,
Steve Jobs created Apple PC's alipuranol fenny tooin phenobarbital, lamotrigene, ethosuximide, penicillans,
carbon, mazopine, and sulfonamides. That's how you remember you're Stephen Johnson
synder medications. Let's do five quick high old questions and then we will wrap
this up. Question one, a nine year old male presents to the office
accompanied by his mother. His mother states that he the boy has had frequent
episodes where he will zone out and stare off into space for a few seconds,
multiple times per day. The mother states the boys unresponsive to her voice
or tactile stimulation during the episodes. The patient has an EEG performed during one
of the episodes in the office which displays a generalized three hurts, spike and
wave appearance. What is the first line medication for the likely diagnosed in this
patient? So we know that is going to be ethosuximide. So this patient
has classic findings of an APPS on seizure, so sudden impairment of consciousness lasting
seconds, occurring multiple times per day. In addition, we have the classic
findings on the eg that three hurt spike and wave pattern. We know first
line med for APPS on seizures is ethosuximide because you remember, if you're absent
into the ether, you will vanish. Question two. Sixty four year old
homeless man is brought into the emergency room by fire rescue. The paramedic state
he has been actively seizing for the entire ride over, which has been over
fifteen minutes. On physical exam, you note a rhythmic jerking of the bilateral
extremities. What is the first line medication class that should be initiated in this
patient? So that is going to be benzodiazepines. So this is status epilepticus,
which is defined as either a single seizure that lasts over five minutes or
if they have more than one seizure without recovery between each episode. This patient
meets that criteria because we see he's been actively seizing over fifteen minutes. So
we know the first line med for status epilepticus is benzos, So that's going
to be diazepe and lorazepam, medazolam if that doesn't work. Next line we
know our if any tones, and then finally pental barbital. Remember he had
to update his tetanus status when ben caught his toin some barbed wire. Question
three, which type of generalized seizure is described by sudden muscle stiffening often associated
with impaired consciousness. So sudden muscle stiffening, remember that is a tonic seizure.
Remember a gin and tonic is a stiff drink that helps you remember a
tonic seizure is a seizure evolving stiffness and rigidity of muscles. Question four,
which anti elliptic medication works by blocking sodium channels? And his first line for
trigeminal neuralgia. So again, remember that is carbamazepine. Because remember carbamazepine,
lift up some salty carbs and chewing them till your cheeks hurt. Remember cheeks
hurt, that's trigeminal neuralgia. This is your first line treatment for trigeminal neuralgia.
Question five, what is the most common type of generalized seizure? So
the most common type of generalize seizure is going to be your toniclonic, your
grandmall seizure. So tonic clonic again, starts with your tonic phase. All
the muscles become stiff after a minute to the chronic phase begins where the muscles
begin to jerk and twitch for an additional one to two minutes. All right,
that is seizures. Thank you so much for listening, and thank you
again so much for the support and good luck in PA school. Good luck
and your pants your panory. You're rs.