S1E43 Seizures

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Alright, so moving along with the Neuro section, 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. 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 hyper synchronization 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 on a vision, 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 memorize all of these, but there is a mnemonic that I've come across. It's not my own, but it's called vitamins. And it stands for some of the more common causes of your provoked seizures. So vitamin stands for V, vascular, so vascular malformation stroke. I stands for infections meningitis and cephalitis. 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, hyponatremia. 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. M 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 meet. In most cases, though, epilepsy just means you've had recurrent seizures. The official diagnostic criteria is either two or more unprovoked seizures occurring more than 24 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, et cetera. 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 a 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 at high risk for a second one. And then the third one is kind of non-specifics 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 generalized 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. You may still hear them being called that. The presentation will be unique in each patient with this type because it really only 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. It's supposed 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 instructions 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-ictal phase and during this time, they may have confusion, headache, for up to several hours. Alright, so let's talk about generalized seizures now. So 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 mal seizure. So most common generalized 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 grand mal seizures, what does this mean? So first let's understand what the term tonic and clonic mean. So tonic means rigidity or 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 clonic phase, which means rhythmic jerking muscle contractions. So usually going to be of the arms, neck, and face. So tonic clonic 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 and twitch, twitch for an additional one to two minutes. And that's your clonic phase. And this is normally followed by a post-ictal phase. All right, so tonic clonic, that's the big one you need to focus on. Let's talk about some other types of generalized 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 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. Clonic, just like we went over in tonic clonic seizures, clonic 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 the 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 and tonic is a stiff drink. So as soon as you see tonic, think of a gin and tonic, which you know is 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 a 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 atonic is, and you can knock out two right there. And then the last one is something known as abson seizures or absin seizures. I think the correct way is absonst, though. These just to be called petite mal 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 eye blinking and lips macking. This can occur hundreds of times per day. And typically each episode will last between five to 10 seconds. A lot of times it's misdiagnosis ADHD. So again, absonst seizure, no loss in muscle tone, but impaired consciousness for just brief periods. No absonst seizures very well. You're going to be tested on this because it has a unique presentation. It has a specific first line med, which we'll 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 absonst seizures. Have a little pneumonic 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 day, I'm long is status epileptic. So the official diagnosis or the official definition of status epileptic 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 last over five minutes or they have more than one seizure without recovery between each episode. It's a medical neurologic emergency. Nurons 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. A lot of times this will be obtained from a friend or family member that witnessed the seizure. You'll need to find out what's going on. Is there any trauma? Is there any drug or alcohol use? Most patients with epilepsy though, we're going to have a fairly unremarkable clinical history. And then of course you want to have a very thorough physical exam, including a neuro exam. And then let's talk about your initial lab work. So your initial laboratory test. You're definitely going to get a rapid blood glucose. You want to make sure this isn't hypoglycemia. You're going to get a CBC, the 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, hyponeatremia. You're also checking your renal function with this, your LFTs. And then you want to do a urinalysis and 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 serum lactate is a good lab to obtain an patient who had an unwitness transient loss of consciousness. So no one to say that yeah, they were season convulsing, flowing 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 syncopal episode or a psychogenic non-apoleptic 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 serum lactate is definitely an important one they 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, insurcreanol, neoplasm, 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 EEG. So once you've ruled out your vitamins, this isn't from vascular stroke, infection, meningitis, and cephalitis, et cetera. You want to obtain an EEG, an electron cephalography. It's not 100% 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 EEG, except for one thing. If you see an aviagnet, they mentioned a three hertz spike in wave pattern, right away, be thinking abson seizure. I wouldn't worry so much about why. Just know if you see three hertz spike in wave pattern in vignet, the answer is abson seizures. You're done. So remember that. So for your diagnostic studies, again, remember three things, neuroimaging, MRI, preferred over CT, your labs checking electrolytes, blood glucose, et cetera. And then an EEG, that's the three main things to focus on for diagnosis. Let's talk about treatment now. So with anti-electic 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 like 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 100% like an abson. What will go over? There is a first line, man, 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 meant 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 meds going to work best to prevent the patient seizure, but which metal 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-aliptic medication. These patients that you're going to start on anti-aliptic medications are specific, specific patients. So for instance, a 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, the 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, though, with their first seizure, you're not going to start an 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 is probably the most important type of seizure for you to know. It's questions always seem to be asked about this and that's absente seizures. So for absente seizures, you have a first line medication. You absolutely have to know. And that's ethosuxamide. That's your first line med, ethosuxamide, ethosuxamide, however you want to pronounce it. That is your first line medication for absente seizures. Second line med would be Valproate. I normally don't recommend memorizing a second line med just because you have so many medications to memorize anyways. But the thing is I was asked it 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 absente seizure is your first line again. It's going to be ethosuxamide. Second line is going to be Valproate. The way that you remember that, hopefully for 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 vanish into the ether. So the way that I remember absente seizures medication regimen is I remember if you're absent, like absent seizure, if you're absent into the ether, you will vanish. So if you're absent, like 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 ethosuxamide. So ether, you will vanish and then vanish. The second word is your second line, and that's Valproate. So that's VA and vanish. That's your first couple letters of Valproate. 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 absente seizures. Remember again, ethosuxamide, first line, Valproate 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 regimen is for status epilepticus. Remember status epilepticus, a seizure that I went on for two days long. So the first thing, first med, first line medication for status epilepticus is going to be your benzo diazopines. 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 their rapid onset. The three most commonly used is going to be diazepam, lorazepam, and medazolam. Lorazepam 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 10 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 neuro consult and EEG, you're going to ramp up the meds. And then next in line, there are some options, but second line will generally be with a fennetone. So phosphenetone, fennetone, that's your second line for status epilepticus. Again, there are some other options, Valproate, Leveratyracetam, which is Keppra, but generally, for exams, for exam purposes, I would remember the fennetones as your second line. And then third line, if they're still seizing at this point, after you've given their fennetones, they need to be intubated. They're going to be on mechanical ventilation. And as far as treatment, you do have some options, but Pento 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 Pento Barbital. Some guidelines will suggest propyl fall continuous infusion with medazolam. At this point, you're basically putting them into a drug induced coma to save them. But again, for the boards, I would tell you to focus on your third or your last line treatment as Pento 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 Pento 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 don't remember one thing, remember benzos. But if you want to remember all three, I do have you way free to remember that. So I just 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 had 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 is he had to update his tetanus status. That helps you remember status epilepticus. When Ben stands for benzo diazopines, remember that's the first word in the 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 Fennito in or Fos Fennito in. So caught his toe in that helps you remember your second line Fennito in some barbed wire that helps you remember a Pento barbed hall. So again, remember status epilepticus for a second and third line meds. He had update his tetanus status status epilepticus when Ben first line Benzo diazopines caught his toe in second line Fennito in some barbed wire. third line is going to be your Pento Barbatol. 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 med 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, et cetera. This is really individualized. And really it's going to be up to our neurologist to decide this. But let's go over some of the more common meds, go over a few nomonics and things you should know for each. So I'm going to focus on the medications that I was tested on the ones that always seem to come up. So the first one you need to know, carbon-masopene. Carbon-masopene is a good med for both focal and generalized seizures. It can cause Steven's Johnson syndrome, like almost all antileptic meds. I have a way for you to remember all those at the end. But the indications that you need to know for carbon-masopene, the first line that it's for, is trigeminal neuralgia. It's a first line med for trigeminal neuralgia. So remember that about carbon-masopene. I said, generally not first line meds for seizures, but that's not a seizure. It's trigeminal neuralgia. So if you know, carbon-masopene is first line for trigeminal neuralgia, that's an important thing to remember. Second thing I would know for carbon-masopene is it's MOA and it blocks sodium channels. And then the third thing I would be aware of for carbon-masopene is one of the higher yield ADRs. And that's that it increases your LFTs. It's hepatotoxic. So again, the three things for carbon-masopene remember, it's first line medication for trigeminal neuralgia. Second thing to know it blocks sodium channels. And third is that it increases your LFTs, your liver function and test it's hepatotoxic. So the way that you remember those three things, is as soon as you see carb-amazepene, carb-amazepene, 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 carb-amazepene, think of salty carbs, think of the sentence, lift up some salty carbs and chew on them until 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 hepatotoxic. LFTs go up some salty carbs salty because that helps you remember it blocks sodium channel. Carbs is carb-amazepene and chew on them until your cheeks hurt. Your cheeks are hurting because remember this patient has trigeminal neuralgia and carb-amazepene is first line for trigeminal neuralgia. Remember you have that pain in the face from the nerves being affected. So again, carb-amazepene, think of salty carbs. Lift up some salty carbs and chew on them until your cheeks hurt. Lift up your LFTs go up, salty carbs because it blocks sodium channels and chew on them until your cheeks hurt. First line for trigeminal neuralgia. That's how you remember what you need to know for carb-amazepene. Moving on to Valproic Acid, also known as Valproate. So this is a broad spectrum anti-eleptic 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 absent seizures. So I'll just really FYI the stuff. Generally it's not gonna be tested on. It's more again for neuro to decide. Now the things that you need to know for Valproic 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 gonna be tested on, these are the ones that I would focus on first. Valproic Acid is Tyradogenic. Now most anti-eleptic medications are tyradogenic to an extent, but Valproic Acid by far is the worst and associated with the highest rate of tyradogenicity of all marketed anti-seizure medications. And for that reason, that's the one that they're gonna test you on. They're gonna be a pregnant patient, ask which med you should avoid in this patient. It's gonna be Valproic. So remember, tyradogenic, 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, this always seems to get tested on. So remember, acute pancreatitis is a possible complication of Valproate therapy. Third thing you need to know, a padotoxic. So acute, padot cellular injury can occur in Valproate. This is usually within the first six months of starting this medication. Some cases, it can actually be associated with Fominant Liver Failure and 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, padotoxicity, and tyradogenic. How you remember that is Valproic Acid, Valproic Acid VPA. The V stands for Vertical Transmission. This helps you remember the tyradogenic effects of the med. I know Vertical Transmission generally first to a pathogen going from the mother of the baby, but in this case, it's gonna help you remember the med, taken by the mother affects the baby. So again, not exactly what vertical transmission means, but whatever gets your mind to helping you remember the tyradogenicity will help you. So V Vertical Transmission. It 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 Hepatocelular Injury. So again, Valproic Acid VPA, Vertical Transmission, AKA, tyradogenic, P pancreatitis, A Acute Hepatocelular Injury. Moving on to Fenni Toen. So Fenni Toen's been around since the 1930s. We're still using it today. It's a good med for focal and generalized seizures. It's good for a Satiseplepticus, as we know, it's second line after Benzos. There's a laundry list of adverse drug reactions from Fenni Toen, but the important ones, the main systemic side effects that you need to remember are one, hersotism, which remember hersotism is an excessive hair growth in women, two, gingival hypertrophy, which is an abnormal overgrowth of gingival tissues and three folic acid depletion. It inhibits folic acid absorption. The other thing too, which again, I'll go over at the end of the way for you to remember this, but it can also cause Stephen Johnson syndrome. So Fenni Toen. What I want you to think of when you think of Fenni Toen is a toe in your mouth. So Fenni 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 gingivitis. That helps you remember the three things that you need to know. So if you put a hairy, hairy helps you remember hersotism, Toen, obviously that's from Fenni Toen, and lick it, L-I-C lick it, that helps you remember folic acid depletion. So hairy hersotism, Toen, Fenni Toen, lick it, folic acid depletion, and then you'll get gingivitis, that helps you remember the gingivol hypertrophy. So again, if you put a hairy toe in your mouth and lick it, you'll get gingivitis, hairy hersotism, Toen, Fenni Toen, lick it, folic acid depletion, and gingivitis, that would be gingivol hypertrophy. And that's Fenni Toen. Okay, so a few other ones that I just wanted to mention, Ethosyxamide we already went over, just to know it does block calcium channels, that's its MOA, and then of course, you know that it's first-line for abson seizures. Really that's the only use for this drug, actually it's a really narrow spectrum medication. So remember, first-line for abson seizures, I keep repeating that because you're gonna get a question on that 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. Penteau Barbatol, 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 epilepticus after Fenni Toen. Levitaracetam, which is Keppra, it's another broad spectrum anti-aleptic 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 meds we went over. There's some other anti-aleptic medications, Lomo trigene, topiramate. There's just not a lot of high-yieldin, info to know for those. And I didn't cover every anti-aleptic medication, there's over 25 of them, so that would be crazy to cover all of them. But again, I did focus on the high-yield ones, the ones that have unique ADRs, the ones that are often tested on. So know those ones that I went over, remember those nomonics. One last little tip, not so crucial to know for seizures in general, but good overall knowledge for the pants, for something that does come up from time to time. So most anti-aleptic meds can cause Stephen Johnson syndrome as we went over. Stephen 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 epidermis. It's pretty serious. So you need to know the meds that can cause it. Again, and most anti-aleptic meds can cause this. But there's some non-antialeptic meds that can cause it too. It's fairly important to know 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 that'll cause this, are by remembering that Stephen Johnson syndrome, I want you to think of Steve Jobs created Apple PC. 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, I want you to think of Steve Jobs. And what did Steve Jobs do? He created Apple PCs. So Stephen Johnson syndrome thinks Steve Jobs created Apple PCs. And Apple PCs stands for all of the main meds that cause Stephen Johnson syndrome. So A, allopurinol, P, Fennetol, P, Feno-barbitol, L, Lomotrogen, E, Ephosuxamide, P, Penicillins, C, Caramazepines, and S, Solphonomides. So again, Steve Jobs created Apple PCs, Allopurinol, Fennetol, Feno-barbitol, Lomotrogen, Fosuxamide, Penicillins, Caramazepine, and Solphonomides. That's how you remember your Stephen Johnson syndrome medications. Let's do five quick, high-yield 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 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 boy's unresponsive toward 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 hertz spike and wave appearance. What is the first line medication for the likely diagnosis in this patient. So we know that is going to be ethylsuxamide. This patient has classic findings of an absente seizure, so sudden impairment of consciousness lasting seconds, occurring multiple times per day. In addition, we have the classic findings on the EEG that three hurts spike in wave pattern. We know first line med for absente seizures is ethylsuxamide because you remember if you're absent and to the ether you will vanish. Question two, 64 year old homeless man is brought into the emergency room by fire rescue. The paramedics state he has been actively seizing for the entire ride over which has been over 15 minutes. On physical exam you know 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 recovered between each episode. This patient meets that criteria because we see he's been actively seizing over 15 minutes. So we know the first line med for status epilepticus is benzo, so that's going to be diazopam, luresopam, medazolam. If that doesn't work, next line we know are fenty toins and then finally pental barbatol. 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 involving stiffness and rigidity of muscles. Question four, which anti-eliptic medication works by blocking sodium channels and is 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 generalized seizure is going to be your tonic clonic, your grandmaw seizures. So tonic clonic again starts with your tonic phase, all the muscles become stiff after a minute to the clonic phase begins where the muscles begin to jerk and twitch from 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 on your pants, your pantry, your URs.