An Approach to Seizures

A discussion of seizure subtypes, etiologies, and evaluation.
#MedEd #ClinicalReasoning

[@sunnyslowenko428]

Thank you for allowing this great lecture and all your other lectures readily available and accessible!!

[@izzatifdzl]

I have been waiting for a topic on seizures from strong medicine! Thank u!

[@tomazlm_]

From my research on UpToDate, Biller's Practical Neurology and some individual articles, hypophosphatemia is not considered a metabolic trigger for seizures, although it may play a role as a biomarker (just like creatine kinase or lactate), since transient hypophosphatemia is common after GTC seizures.

[@StrongMed]

Thanks for the comment. I am not an expert on hypophosphatemia, but from the UpToDate article, "Hypophosphatemia: Clinical Manifestations of Phosphate Depletion": "Severe hypophosphatemia, defined as a phosphate concentration below 1 mg/dL (0.32 mmol/L), can lead to metabolic encephalopathy that results from ATP depletion. A broad spectrum of neurologic symptoms have been associated with prolonged phosphate depletion, ranging from mild irritability and paresthesias to more severe manifestations such as delirium, generalized seizures, and coma." But there are obviously major confounders in determining a cause-and-effect relationship, as calcium and phosphate disorder often co-exist, and one of the most common causes of new onset seizures in adults, alcohol withdrawal, is associated with hypophosphatemia from nutritional deficiencies. If you happen to read French (I don't), there is an article that discusses the conundrum between deciding if hypophosphatemia is the cause of a GTC or just a biomaker: pubmed.ncbi.nlm.nih.gov/36170139/

[@user-wz6oo9bq5j]

Thanks for the great video (as always!). I have a loosely-connected question about lidocaine. I encountered two cases of seizures in a patient with VT both were attributed to lidocaine loading dose (~ 100 mg ) with no kidney or liver disease. I'm wondering about the mechanism behind which lidocaine can cause seizures (isn't lidocaine a Na channel blocker and thus "should" be a "seizure medication" like phenytoin ? Fortunately, the two cases were both ~ 2 minutes and responded well to IV diazepam [and VT was converted but with no maintenance dose of lidocaine but rather looking for other AADs] ).

[@sunving]

Thank you Dr Eric Strong , great lecture .

[@bb0ss]

Really great and practical guide

[@msrj899]

Really appreciate this channel.

[@ghadeernajim310]

Doctor firstly thank you for your great videos and explanation Secondly please which guidelines are best for internal medicine

[@StrongMed]

You are welcome! Regarding your question about guidelines, it totally depends on the specific topic. For example, for guidelines on COPD management, I would recommend GOLD. For pretty much anything cardiac related, I'd recommend the AHA/ACC joint guidelines (or ESC guidelines) on the relevant disease. For primary care, I usually look at the USPSTF recs, though they have sometimes been controversial for giving different recs than the relevant subspecialty societies.

[@ghadeernajim310]

Ahh 😊😊 thank you so much doctor for your answer 🌸🌸

[@iNayefm]

Thank you Dr Strong for your enormous effort, it is much appreciated. If i may ask, Have you done an approach to joint pain ?

[@StrongMed]

Just back pain. Approaches to knee and shoulder pain in particular, as well as an overview of inflammatory arthritis are on my long list of topics to cover, but with so many other potential topics, unfortunately, I don't anticipate getting to them in the near future.

[@user-ii9hm7jh6w]

thank you very much thanking you professor is the least we can do

[@moradzayed]

very informative thank you

[@stringomyelin]

Sir, if you may, please update the playlists on this channel. Very helpful to save them instead of making new for different topics. This would very well go in your existing playlist by the title "An Approach to Symptoms." Thankyou.

[@StrongMed]

Thanks for watching and for the comment, however this video is already in the "Approach to Symptoms" playlist. (You may have missed it because the playlist is organized by organ system/specialty rather than by upload date)

[@stringomyelin]

@@StrongMed I'm sorry to have missed. Thankyou so much for replying and helping out. Very grateful for your lectures.

[@fredbloggs8816]

Very interested to know what proportion of US patients end up categorised as epilepsy but with no known cause.

[@TheCriticalCarePractitioner]

Hi Eric- looks like you have changed style slightly over the years. Are you using a studio these days and more of a team (my dream), or is it still all you?

[@StrongMed]

Jonathan - it's been a long time! I hope you've been well. It's still just me for the most part. I moved recording from my dining room to the basement when we finally bought a house a few years ago, which is nice because I could give it some degree of long-term sound treatment, and because I can leave the equipment up between recordings. That's why I have retired the narrated PowerPoint style videos that was all I had done for the first 4-5 years of the channel. Coincidentally, for my most recent videos that I've been publishing over the last 2 months, I've been working with the Stanford Standardized Patient Program to hire actors/actresses for physical exam demonstrations, and someone from the program has been a huge help with the shoots done at the med school. I also have an on-location video that's being posted on Sunday for which my son was the cameraman, but it's just a one-off thing.

[@AmarHimd]

Thanks again for the great video Dr. Strong. I have a question in regard to the EEG, is the EEG beneficial tool in the work up? I can't thank you more for sharing your awesome videos!!!

[@StrongMed]

I'm so sorry, I'm just seeing your question now! In short, yes, an EEG is a standard part of the evaluation of unprovoked seizures, particularly if it's unclear if a patient is experiencing "epileptic" vs. "non-epileptic" seizures, or non-convulsive seizures. It can also be critical to identify a specific primary epilepsy syndrome. EEGs are not featured in this video because this video is focused on ED, urgent care, and general medicine presentations, whereas decisions to get an EEG are almost always made by a neurologist.

[@AmarHimd]

@@StrongMed Thank you so much! I appreciate you taking the time to answer my question in such an informative replay. Thanks again for the great video.

[@user-in3bw5it2x]

great video ! could you please upload the slides to the google drive folder ? thanks !

[@VyewVyew]

Thanks for another great video Dr Strong. Here in the UK it’s common to do ABGs immediately after a seizure to use the lactate as a way of “proving” a real seizure occurred as for whatever reason we have a high rate of inpatient non-epileptic attack disorder, vasovagals with myoclonus, and intermittent unresponsive episodes with some twitching in delirious demented patients which get labeled as possible seizures. Is this a common practice in the US, or do you guys use other means of “proving” a real seizure immediately after the rapid response call?

[@StrongMed]

That's a great question. I have not seen that done in the US, and my gut reaction was to recommend against it...but, I just did a literature search and found this paper finding utility in paramedics getting a point-of-care lactate level in the field to distinguish epileptic from non-epileptic seizure: www.ncbi.nlm.nih.gov/pmc/articles/PMC7898511/ (provided that the threshold used to distinguish the two was higher than the upper limit of normal)

[@Siddhansh12345]

Thank you Doctor for your videos, do you have any advice for those sitting for Canadian licensing exams?

[@StrongMed]

I'm so sorry, I'm just seeing this question now. Unfortunately, I am not familiar with Canadian licensing exams. If you already took it, I hope it went well!

[@nadirabbas8114]

Thanx

[@drkanwalabbasbhatti1625]

very nice sir sir some videos regarding endocrinology plz upload

[@Tonguebiter360]

Post ictal phase is when I vomit for at least 30 minutes and I’m not a very friendly person

[@MonaSax-ir6cw]

Back when I was 15 I used to have seizures and they were scary as hell

[@RobertWWD]

I was diagnosed with Epilepsy when I was 2 and had a Brain Tumor surgically removed when I was 8. 24 years Seizure free.

[@areufkingkiddingme]

I hate whoever named these seizures