WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:32.810 fast. Welcome to the emergency room. 45 minutes 00:00:32.810 --> 00:00:48.070 of CPR. We can stop CPR. Welcome back to The 00:00:48.070 --> 00:00:50.670 Deep Dive. Today we are wading into waters that 00:00:50.670 --> 00:00:53.049 I think terrify just about everyone, parents, 00:00:53.149 --> 00:00:55.450 teachers, and honestly even a lot of seasoned 00:00:55.450 --> 00:00:57.549 medical professionals. Oh, absolutely. We are 00:00:57.549 --> 00:00:59.390 looking at the pediatric brain, specifically 00:00:59.390 --> 00:01:02.469 when it kind of goes rogue. We're talking about 00:01:02.469 --> 00:01:05.010 seizures. It's a heavy topic. Now in this sack 00:01:05.010 --> 00:01:06.969 of research we're looking at today, the nursing 00:01:06.969 --> 00:01:09.769 textbooks, the clinical tables, specifically 00:01:09.769 --> 00:01:12.870 table 16 .2, plus those dense lecture notes, 00:01:13.329 --> 00:01:17.150 there is this undercurrent of urgency. Because 00:01:17.150 --> 00:01:20.150 when a child has a seizure, it looks chaotic. 00:01:20.390 --> 00:01:22.489 It looks like a medical catastrophe. I feel like 00:01:22.489 --> 00:01:24.609 a system crash. I mean, looking at the descriptions 00:01:24.609 --> 00:01:27.310 of a tonic -clonic seizure, it's violent. It 00:01:27.310 --> 00:01:30.049 is violent. And for a nurse or a parent, the 00:01:30.049 --> 00:01:32.590 instinct is to panic. The adrenaline dumps, and 00:01:32.590 --> 00:01:33.969 you want to do something immediately. Right, 00:01:33.969 --> 00:01:36.329 you want to fix it. But the materials we are 00:01:36.329 --> 00:01:39.510 diving into today make a very specific promise. 00:01:40.209 --> 00:01:42.709 They argue that if you can move past the fear, 00:01:43.370 --> 00:01:45.650 seizures actually follow a very strict set of 00:01:45.650 --> 00:01:48.340 rules. That's what jumped out at me. I went into 00:01:48.340 --> 00:01:51.060 this expecting just a list of terrifying symptoms. 00:01:51.599 --> 00:01:53.620 You know, just a catalog of bad things. Right. 00:01:54.120 --> 00:01:56.799 But what we actually have here is a logic puzzle. 00:01:57.120 --> 00:01:59.299 The sources call it a classification system, 00:01:59.659 --> 00:02:02.939 but it feels more like a map. It is a map. And 00:02:02.939 --> 00:02:05.359 that's our mission for this deep dive. We aren't 00:02:05.359 --> 00:02:07.980 just going to memorize a list of jerks and twitches. 00:02:08.080 --> 00:02:10.719 We are going to try to build what I call a safety 00:02:10.719 --> 00:02:13.099 brain. A safety brain. I like that. We want to 00:02:13.099 --> 00:02:15.919 get to a point where If you see a child in distress, 00:02:16.439 --> 00:02:18.099 you aren't thinking, oh my god, you're thinking, 00:02:18.300 --> 00:02:20.259 okay, looking at the map, I know exactly where 00:02:20.259 --> 00:02:22.219 we are and I know exactly what to do. That's 00:02:22.219 --> 00:02:24.979 the goal, right? To move from panic to a plan. 00:02:25.680 --> 00:02:27.360 Because looking at these notes, there is a lot 00:02:27.360 --> 00:02:30.939 of noise. You have tonic, clonic, atonic, myoclonic, 00:02:31.439 --> 00:02:34.439 absence focal. Complex partial, simple partial. 00:02:34.539 --> 00:02:36.460 It's an alphabet soup. It's an alphabet soup 00:02:36.460 --> 00:02:39.400 of neurology. It's so easy to get lost. It is. 00:02:39.419 --> 00:02:41.740 And that's where students fail exams and where 00:02:41.740 --> 00:02:43.580 clinicians make mistakes. They try to memorize 00:02:43.580 --> 00:02:47.479 the soup. We need to apply the 80 -20 rule here. 00:02:47.699 --> 00:02:50.280 OK, lay out the 80 -20 rule for pediatric seizures. 00:02:50.439 --> 00:02:52.919 What are we focusing on? So we're going to ignore 00:02:52.919 --> 00:02:55.599 the one in a million neurological outliers for 00:02:55.599 --> 00:02:58.639 a moment. The house MD stuff. Exactly. We're 00:02:58.639 --> 00:03:01.139 going to focus on the 20 % of core concepts, 00:03:01.520 --> 00:03:04.460 that's classification, safety, and prioritization, 00:03:04.919 --> 00:03:07.439 that solve 80 % of the problems you will face 00:03:07.439 --> 00:03:11.060 at the bedside or on the NCLEX. OK. If you understand 00:03:11.060 --> 00:03:13.639 the mechanism, you don't need to memorize every 00:03:13.639 --> 00:03:18.319 single variation. So less rare diagnoses, more 00:03:18.319 --> 00:03:21.099 emergency room practical survival. Precisely. 00:03:21.379 --> 00:03:23.580 We need to know what kills the patient, what 00:03:23.580 --> 00:03:26.060 damages the brain, and how to keep them safe 00:03:26.060 --> 00:03:28.530 while the storm passes. Okay, let's open up the 00:03:28.530 --> 00:03:30.909 map. The first thing the literature demands is 00:03:30.909 --> 00:03:33.169 that we stop thinking of a seizure as just shaking 00:03:33.169 --> 00:03:36.030 on the floor. Right. Shaking is just one potential 00:03:36.030 --> 00:03:38.370 symptom. To really understand this, you have 00:03:38.370 --> 00:03:40.110 to look at the engine. You have to look at the 00:03:40.110 --> 00:03:42.969 brain as an electrical grid. I like this analogy 00:03:42.969 --> 00:03:45.210 in the notes. So imagine a city like New York 00:03:45.210 --> 00:03:47.550 or London at night. The lights are on, traffic 00:03:47.550 --> 00:03:49.349 signals are working, everything is flowing. That's 00:03:49.349 --> 00:03:52.370 a normal brain. Correct. Neural pathways are 00:03:52.370 --> 00:03:55.330 firing in an organized sequence. A seizure is 00:03:55.330 --> 00:03:57.879 an electrical storm. It's a massive, uncontrolled 00:03:57.879 --> 00:04:00.979 discharge of energy. But, and this is the absolute 00:04:00.979 --> 00:04:03.819 key to the entire deep dive, the name we give 00:04:03.819 --> 00:04:07.319 that storm depends on two questions. Question 00:04:07.319 --> 00:04:11.300 one, where did the lightning strike? Yes, the 00:04:11.300 --> 00:04:13.939 location of the onset. Did it start in one specific 00:04:13.939 --> 00:04:16.639 building in one neighborhood or did the entire 00:04:16.639 --> 00:04:19.439 grid short circuit simultaneously? And question 00:04:19.439 --> 00:04:22.920 two, did the lights go out? Exactly. Consciousness. 00:04:23.339 --> 00:04:25.439 Did the patient stay awake? or did the system 00:04:25.439 --> 00:04:28.120 crash? If you can answer those two questions, 00:04:28.399 --> 00:04:30.459 location and consciousness, you can classify 00:04:30.459 --> 00:04:32.379 almost any seizure you'll ever see. So let's 00:04:32.379 --> 00:04:35.240 apply this to the big buckets in table 16 .2. 00:04:35.319 --> 00:04:38.439 The first bucket is generalized onset. Using 00:04:38.439 --> 00:04:40.379 our grid analogy, this sounds like the worst 00:04:40.379 --> 00:04:42.519 case scenario. It's the city -wide blackout. 00:04:42.540 --> 00:04:44.879 In a generalized onset seizure, the electrical 00:04:44.879 --> 00:04:47.379 discharge involves both hemispheres of the brain, 00:04:47.680 --> 00:04:50.120 the entire city, from the very first millisecond. 00:04:50.279 --> 00:04:52.720 So there's no warning, no buildup? None. Just 00:04:52.720 --> 00:04:55.040 bam, the whole grid is hit. And because the whole 00:04:55.040 --> 00:04:57.579 brain is involved, I'm assuming the lights question 00:04:57.579 --> 00:05:00.180 is pretty easy to answer. There is almost nowhere 00:05:00.180 --> 00:05:02.519 for consciousness to hide. If your whole brain 00:05:02.519 --> 00:05:05.420 is seizing, you cannot be conscious. You might 00:05:05.420 --> 00:05:07.800 not be on the floor shaking, but you are not 00:05:07.800 --> 00:05:10.439 there. Right. You aren't processing information. 00:05:11.220 --> 00:05:13.939 The reticular activating system, the part of 00:05:13.939 --> 00:05:16.500 the brain that keeps you awake, is overwhelmed 00:05:16.500 --> 00:05:20.060 instantly. OK, so generalized equals whole brain 00:05:20.060 --> 00:05:23.430 and usually lights out. Now, the notes split 00:05:23.430 --> 00:05:25.769 this bucket into two subcategories that sound 00:05:25.769 --> 00:05:28.949 pretty self -explanatory, motor and non -motor. 00:05:29.110 --> 00:05:31.370 And this is where the movies mislead us. We expect 00:05:31.370 --> 00:05:33.490 the motor stuff, the flashing, the convulsions, 00:05:33.509 --> 00:05:36.540 but a generalized seizure can be... non -motor. 00:05:36.660 --> 00:05:39.160 The person just stops, they freeze, the storm 00:05:39.160 --> 00:05:41.459 is raging inside, but the outside looks eerily 00:05:41.459 --> 00:05:43.980 calm. We'll dig into those specific types, the 00:05:43.980 --> 00:05:46.459 daydreamers versus the drop attacks in a bit, 00:05:46.459 --> 00:05:49.139 but I want to contrast the city -wide blackout 00:05:49.139 --> 00:05:52.240 with the second bucket, focal onset. Focal is 00:05:52.240 --> 00:05:54.839 the opposite. This is a transformer blowing up 00:05:54.839 --> 00:05:57.860 on a single street corner. The storm originates 00:05:57.860 --> 00:06:00.600 in one specific group of neurons in one hemisphere. 00:06:00.939 --> 00:06:03.139 So the rest of the city might still have power. 00:06:03.360 --> 00:06:05.939 Exactly. And this is where it gets tricky for 00:06:05.939 --> 00:06:08.480 the nurse or the parent observing. Because only 00:06:08.480 --> 00:06:11.139 part of the brain is offline, the child might 00:06:11.139 --> 00:06:13.639 still be awake. This is that concept of the toggle 00:06:13.639 --> 00:06:16.319 switch regarding awareness. I found that really 00:06:16.319 --> 00:06:19.079 helpful. Right. We classify these based on awareness. 00:06:19.459 --> 00:06:22.160 You can have focal with retained awareness. The 00:06:22.160 --> 00:06:24.259 child knows they're having a seizure. They might 00:06:24.259 --> 00:06:27.100 look at you and say, my arm feels weird or I 00:06:27.100 --> 00:06:29.939 smell burning rubber. The lights are flickering, 00:06:30.199 --> 00:06:33.399 but they are on. That sounds almost more terrifying 00:06:33.399 --> 00:06:35.860 than being unconscious, to be a witness to your 00:06:35.860 --> 00:06:38.639 own brain malfunction. It can be incredibly traumatic 00:06:38.639 --> 00:06:40.920 for a child. They feel out of control, but they 00:06:40.920 --> 00:06:43.500 are fully present. They can hear you speaking 00:06:43.500 --> 00:06:45.339 to them, but they might not be able to control 00:06:45.339 --> 00:06:48.180 the twitching in their hand. Yeah, it's frightening. 00:06:48.420 --> 00:06:50.720 But then there is focal with impaired awareness. 00:06:50.939 --> 00:06:54.060 The switch goes down halfway. The storm in that 00:06:54.060 --> 00:06:56.439 one neighborhood spreads just enough to fog up 00:06:56.439 --> 00:06:58.980 the windows. They aren't unconscious. They aren't 00:06:58.980 --> 00:07:01.519 in a coma. but they aren't home either. What 00:07:01.519 --> 00:07:03.019 does that look like? They might look at you, 00:07:03.060 --> 00:07:05.100 but they look through you. They don't answer 00:07:05.100 --> 00:07:07.240 a question, but the answer makes no sense. They're 00:07:07.240 --> 00:07:09.600 just not connecting. So to recap the map before 00:07:09.600 --> 00:07:12.839 we zoom in, generalized is the whole grid, lights 00:07:12.839 --> 00:07:16.360 out. Focal is one neighborhood. Lights might 00:07:16.360 --> 00:07:18.899 be on or they might be dimmed. You've got it. 00:07:19.019 --> 00:07:21.079 And then there is the third bucket, the unknown 00:07:21.079 --> 00:07:24.000 onset, which is the medical way of saying we 00:07:24.000 --> 00:07:25.899 didn't see the start, so we aren't sure. Right, 00:07:26.000 --> 00:07:28.490 the catchall. It is, but that's where we hide 00:07:28.490 --> 00:07:31.050 one of the most dangerous monsters in pediatric 00:07:31.050 --> 00:07:34.689 neurology infantile spasms. Which we will definitely 00:07:34.689 --> 00:07:36.569 get to because the research on that is urgent. 00:07:37.029 --> 00:07:38.810 But before we leave the high level map, I want 00:07:38.810 --> 00:07:41.269 to test the safety brain theory. I'm going to 00:07:41.269 --> 00:07:44.069 throw a scenario at you, a pattern, and you tell 00:07:44.069 --> 00:07:46.870 me where it fits on the grid. Let's do it. Scenario 00:07:46.870 --> 00:07:51.110 one. You're a school nurse. A teacher sends a 00:07:51.110 --> 00:07:53.350 note saying a seven year old student keeps spacing 00:07:53.350 --> 00:07:56.199 out during math. He just stares at the wall for 00:07:56.199 --> 00:07:58.720 10 seconds, doesn't answer when called, and then 00:07:58.720 --> 00:08:00.920 snaps back and keeps working like nothing happened. 00:08:01.240 --> 00:08:04.660 OK. Look at the grid. Is he moving? No. So it's 00:08:04.660 --> 00:08:07.319 non -motor. Is he conscious? No, he's not answering 00:08:07.319 --> 00:08:09.939 you. He's not processing. And he snaps back instantly. 00:08:10.279 --> 00:08:13.600 This is classic generalized non -motor, specifically 00:08:13.600 --> 00:08:17.360 an absence seizure. Absence. It's such a perfect 00:08:17.360 --> 00:08:20.040 name. He's just... Absent. He's gone for a few 00:08:20.040 --> 00:08:22.720 seconds, and the snapping back is the tell. If 00:08:22.720 --> 00:08:24.699 he was just bored, he'd be annoyed if he interrupted 00:08:24.699 --> 00:08:26.360 him. If it's a seizure, he doesn't even know 00:08:26.360 --> 00:08:27.720 he was gone. Great, there's no memory of it. 00:08:27.860 --> 00:08:31.019 Not at all. Okay, scenario two. This one is more 00:08:31.019 --> 00:08:33.700 dramatic. A child is walking down the hallway 00:08:33.700 --> 00:08:36.740 and suddenly, boom, drops to the floor like a 00:08:36.740 --> 00:08:40.200 puppet with cut strings, hits his face, no bracing, 00:08:40.320 --> 00:08:42.659 no stumbling, just a complete drop. Gravity takes 00:08:42.659 --> 00:08:45.340 over. That's a sudden total loss of muscle tone. 00:08:45.419 --> 00:08:48.700 We call that a tonic. A for, without, a tonic 00:08:48.700 --> 00:08:50.759 for tone. A tonic, got it. That's generalized 00:08:50.759 --> 00:08:53.899 motor. And your safety brain should immediately 00:08:53.899 --> 00:08:58.159 be screaming, head injury! Elvet. Helmet, 100%. 00:08:58.159 --> 00:08:59.860 If you see a kid in the classroom with a helmet, 00:09:00.019 --> 00:09:01.899 assume a tonic seizures until proven otherwise. 00:09:02.460 --> 00:09:06.179 Scenario three. A toddler has a high fever, 104 00:09:06.179 --> 00:09:09.740 degrees Fahrenheit. Suddenly, eyes roll back, 00:09:10.279 --> 00:09:13.059 shaking all over for two minutes, then stops 00:09:13.059 --> 00:09:16.419 and cries. That is the most common one. Febrile 00:09:16.419 --> 00:09:18.639 seizure. It looks like a generalized motor seizure, 00:09:19.200 --> 00:09:21.480 but the trigger is the fever, the rapid rise 00:09:21.480 --> 00:09:24.360 in temperature. This is a specific pediatric 00:09:24.360 --> 00:09:27.000 category that requires calm education for the 00:09:27.000 --> 00:09:30.269 parents, not necessarily panic. So it's scary, 00:09:30.370 --> 00:09:33.330 but it's not necessarily epilepsy. Correct. It's 00:09:33.330 --> 00:09:35.710 a reaction, not a chronic condition. Okay. I 00:09:35.710 --> 00:09:37.269 feel like I have the grid in my head. Now I want 00:09:37.269 --> 00:09:38.809 to get into the weeds. I want to go through section 00:09:38.809 --> 00:09:40.730 B, the seizure type breakdown. Let's start with 00:09:40.730 --> 00:09:42.649 the big one. The one that everyone pictures when 00:09:42.649 --> 00:09:44.850 they hear the word epilepsy. The generalized 00:09:44.850 --> 00:09:48.700 motor, specifically the tonic clonic. The notes 00:09:48.700 --> 00:09:50.519 refer to this as the tonic -clonic, but I grew 00:09:50.519 --> 00:09:53.320 up hearing it called grand mal. Why did we change 00:09:53.320 --> 00:09:56.100 the name? Grand mal is French for great sickness. 00:09:56.480 --> 00:09:58.820 It's dramatic, sure, but it's not helpful. It 00:09:58.820 --> 00:10:00.720 doesn't tell you anything. It's a bit archaic. 00:10:01.000 --> 00:10:03.220 Very. Medicine is trying to be more descriptive. 00:10:04.080 --> 00:10:06.559 Tonic -clonic is a literal instruction manual 00:10:06.559 --> 00:10:09.440 for what the muscles are doing. Tonic means stiffening. 00:10:09.679 --> 00:10:12.879 Clonic means jerking. So break it down. If I'm 00:10:12.879 --> 00:10:15.259 a new nurse or a parent and this starts happening, 00:10:15.669 --> 00:10:18.570 What is the sequence? Because the notes say it 00:10:18.570 --> 00:10:21.590 follows a script. It almost always follows a 00:10:21.590 --> 00:10:23.669 script. And knowing the script is the only way 00:10:23.669 --> 00:10:26.409 to keep your cool when everything is chaos. Acts 00:10:26.409 --> 00:10:29.809 one is the aura. Now, this doesn't always happen, 00:10:30.049 --> 00:10:32.090 but when it does, it's a warning shot. This is 00:10:32.090 --> 00:10:34.409 the pre -shock, the warning. Right. And physically, 00:10:34.610 --> 00:10:36.730 this is actually a focal seizure happening before 00:10:36.730 --> 00:10:39.250 it spreads to the whole brain. The child might 00:10:39.250 --> 00:10:41.710 smell something distinct. Burnt toast is the 00:10:41.710 --> 00:10:44.509 cliche, but it could be anything. Or they get 00:10:44.509 --> 00:10:47.250 a sudden overwhelming sense of deja vu or dread. 00:10:47.529 --> 00:10:49.950 It's the calm before the storm. And then the 00:10:49.950 --> 00:10:52.710 storm breaks. This is act two, the tonic phase. 00:10:52.990 --> 00:10:54.789 And this moment is usually marked by a sound 00:10:54.789 --> 00:10:57.870 that parents never forget, the epileptic cry. 00:10:58.210 --> 00:11:00.370 I've read about this. It's described as a scream, 00:11:00.509 --> 00:11:02.909 but the notes emphasize that it's not a cry of 00:11:02.909 --> 00:11:05.370 pain. That's a crucial distinction for the family. 00:11:05.649 --> 00:11:09.049 It sounds like agony, but it's physics. The tonic 00:11:09.049 --> 00:11:11.250 phase means every muscle in the body instantly 00:11:11.250 --> 00:11:13.429 stiffens. That includes the diaphragm and the 00:11:13.429 --> 00:11:16.230 chest wall. They clamp down violently, forcing 00:11:16.230 --> 00:11:18.690 all the air out of the lungs through vocal cords 00:11:18.690 --> 00:11:20.909 that have also clamped shut. So it's not a voice. 00:11:21.190 --> 00:11:24.730 It's just air. It's a high pressure squeak. A 00:11:24.730 --> 00:11:27.529 very loud, terrifying mechanical squeak. And 00:11:27.529 --> 00:11:29.769 at that exact moment, consciousness is gone. 00:11:29.929 --> 00:11:33.649 The child falls. The body is rigid. Arms flexed. 00:11:33.649 --> 00:11:36.190 Legs extended. Back arched. And because those 00:11:36.190 --> 00:11:39.009 chest muscles are clamped, they aren't breathing. 00:11:39.269 --> 00:11:41.950 They are in apnea. They are not moving air. This 00:11:41.950 --> 00:11:44.009 is why you see cyanosis, that blue tint around 00:11:44.009 --> 00:11:46.250 the lips. As a nurse, this is the part that makes 00:11:46.250 --> 00:11:48.309 your heart stop. You're watching a child turn 00:11:48.309 --> 00:11:50.850 blue. The instinct is to do something. Breathe 00:11:50.850 --> 00:11:52.809 for them. Shake them. And you can't. You have 00:11:52.809 --> 00:11:55.210 to write it out. Because usually within 10 to 00:11:55.210 --> 00:11:58.129 20 seconds, the brain shifts gears into act three. 00:11:58.320 --> 00:12:02.000 The clonic phase. The jerking. This is the rhythmic 00:12:02.000 --> 00:12:04.600 part. The muscles start rapidly contracting and 00:12:04.600 --> 00:12:07.840 relaxing. It's violent. And this brings us to 00:12:07.840 --> 00:12:10.399 the gross reality of seizures that textbooks 00:12:10.399 --> 00:12:12.899 sometimes gloss over, but you need to be ready 00:12:12.899 --> 00:12:14.919 for at the bedside. The fluids. There's a lot 00:12:14.919 --> 00:12:17.539 of fluid. Because the swallowing reflex is gone, 00:12:17.740 --> 00:12:20.379 saliva is pooling in the throat. The jerking 00:12:20.379 --> 00:12:22.299 churns it into a foam. It looks like something 00:12:22.299 --> 00:12:24.500 from a horror movie, but it's just spit. And 00:12:24.500 --> 00:12:26.860 they might bite their tongue. Often. So now the 00:12:26.860 --> 00:12:30.100 foam is pink or bloody. and simultaneously the 00:12:30.100 --> 00:12:32.799 sphincter muscles let go so the child might wet 00:12:32.799 --> 00:12:35.279 themselves or have a bowel movement. Okay, paint 00:12:35.279 --> 00:12:39.620 the picture. You have a child who is blue, thrashing, 00:12:40.000 --> 00:12:42.600 foaming blood at the mouth and has lost bladder 00:12:42.600 --> 00:12:46.279 control. It is a scene of absolute chaos. Total 00:12:46.279 --> 00:12:49.460 chaos. So safety brain on, what is the one thing 00:12:49.460 --> 00:12:51.899 you see people do in movies that you must never, 00:12:51.899 --> 00:12:53.860 ever do in this moment? You never put anything 00:12:53.860 --> 00:12:55.820 in their mouth. Put a wallet in, put a spoon 00:12:55.820 --> 00:12:57.580 in so they don't swallow their tongue. Myth, 00:12:57.860 --> 00:13:00.639 myth, myth. You cannot swallow your tongue. It's 00:13:00.639 --> 00:13:02.019 attached to the bottom of your mouth. But if 00:13:02.019 --> 00:13:05.039 you shove a spoon in there, You will chip their 00:13:05.039 --> 00:13:07.740 teeth, you will lacerate their gums. Or worse. 00:13:08.220 --> 00:13:10.899 Or worse, you'll trigger a gag reflex and make 00:13:10.899 --> 00:13:13.480 them vomit while they're on their back, unable 00:13:13.480 --> 00:13:15.840 to clear their airway. You turn a seizure into 00:13:15.840 --> 00:13:17.879 a choking hazard. You turn it into an aspiration 00:13:17.879 --> 00:13:22.019 event. Yeah. Exactly. And the other, don't. Do 00:13:22.019 --> 00:13:24.799 not restrain them. Why, if they're thrashing, 00:13:24.919 --> 00:13:26.519 shouldn't I hold them down so they don't get 00:13:26.519 --> 00:13:29.240 hurt? The force of a tonic -clonic seizure is 00:13:29.240 --> 00:13:32.210 incredibly powerful. The muscles are contracting 00:13:32.210 --> 00:13:35.649 with maximum force. If you try to pin a child's 00:13:35.649 --> 00:13:38.149 arm to the floor, the muscle contraction is strong 00:13:38.149 --> 00:13:40.870 enough to snap their own bone against your resistance. 00:13:41.669 --> 00:13:44.850 You will cause a fracture. Wow. So the nursing 00:13:44.850 --> 00:13:47.629 intervention is let it happen. It's counterintuitive. 00:13:47.710 --> 00:13:49.970 So counterintuitive. You let it happen, but you 00:13:49.970 --> 00:13:52.769 make it safe. You become the goalie. You push 00:13:52.769 --> 00:13:55.110 away the furniture. You put a pillow or a jacket 00:13:55.110 --> 00:13:56.750 under their head so they don't crack their skull 00:13:56.750 --> 00:13:59.580 on the linoleum. OK. And if you can... Only if 00:13:59.580 --> 00:14:01.779 you do it safely, you roll them to their side. 00:14:01.820 --> 00:14:03.820 You drain the foam. Gravity is your suction. 00:14:04.080 --> 00:14:05.840 Let the saliva run out so it doesn't go into 00:14:05.840 --> 00:14:09.899 the lungs. Okay. The jerking stops. Silence falls. 00:14:10.519 --> 00:14:13.799 The seizure is over. But the episode isn't, right? 00:14:13.919 --> 00:14:16.320 The danger's not over. Not even close. This is 00:14:16.320 --> 00:14:19.440 act four, the postictal state. And this is where 00:14:19.440 --> 00:14:22.259 the tonic -clonic is unique. The brain has just 00:14:22.259 --> 00:14:25.860 run a marathon at a sprint pace. It is chemically 00:14:25.860 --> 00:14:28.179 exhausted. So the child doesn't just pop up and 00:14:28.179 --> 00:14:31.220 ask for a snack? No. They are dead weight. They 00:14:31.220 --> 00:14:34.299 are usually difficult to rouse, confused, maybe 00:14:34.299 --> 00:14:36.740 combative if you try to wake them. They need 00:14:36.740 --> 00:14:39.779 sleep, deep sleep, for 30 minutes, maybe two 00:14:39.779 --> 00:14:43.399 hours. And this is a diagnostic clue. Huge clue. 00:14:43.919 --> 00:14:45.940 If the teacher says he shook for a minute and 00:14:45.940 --> 00:14:48.080 then went right back to math, that wasn't a tonic 00:14:48.080 --> 00:14:50.620 -clonic. Right. If they say he shook and now 00:14:50.620 --> 00:14:52.340 he's been asleep in the nurse's office for an 00:14:52.340 --> 00:14:54.899 hour and doesn't know his own name, that's tonic 00:14:54.899 --> 00:14:57.139 -clonic. The recovery time tells you the severity 00:14:57.139 --> 00:14:59.360 of the storm. Before we move off the generalized 00:14:59.360 --> 00:15:01.600 motor types, we mentioned a tonic earlier, the 00:15:01.600 --> 00:15:03.480 drop attack. Is there anything else about that 00:15:03.480 --> 00:15:05.860 one we need to lock in? Just remember the Lennox 00:15:05.860 --> 00:15:09.360 -Gastaut connection. It's a severe form of childhood 00:15:09.360 --> 00:15:13.360 epilepsy. These kids have mixed seizures. Tonic, 00:15:13.399 --> 00:15:16.139 a tonic absence. But the a tonic ones are the 00:15:16.139 --> 00:15:18.600 most dangerous for daily life because they happen 00:15:18.600 --> 00:15:21.259 without warning. The helmet isn't a fashion statement. 00:15:21.299 --> 00:15:23.940 It's a medical device. It's essential equipment. 00:15:24.029 --> 00:15:27.029 It is. And myoclonic, that's another motor term. 00:15:27.190 --> 00:15:30.049 Think of the myo meaning muscle and clonic meaning 00:15:30.049 --> 00:15:33.590 jerk. But myoclonic is like a lightning strike. 00:15:33.710 --> 00:15:35.490 It's a single massive jerk. You know when you're 00:15:35.490 --> 00:15:37.429 falling asleep or your whole body kicks? A startle 00:15:37.429 --> 00:15:39.730 response? Yeah, it's a hypnic jerk. It's like 00:15:39.730 --> 00:15:42.110 that, but while awake and much more violent, 00:15:42.169 --> 00:15:45.450 it's usually brief milliseconds. But it can be 00:15:45.450 --> 00:15:47.909 strong enough to make a child throw a spoon across 00:15:47.909 --> 00:15:50.250 the room or fall out of a chair. It's a sudden, 00:15:50.750 --> 00:15:53.649 powerful misfire. Okay, let's flip the coin. 00:15:54.299 --> 00:15:57.460 Still generalized, so whole brain but non -motor. 00:15:57.960 --> 00:15:59.820 We talked about the daydreaming student, the 00:15:59.820 --> 00:16:02.220 absence seizure. Formally, petty mal. Little 00:16:02.220 --> 00:16:04.840 sickness. Why do exam writers love this one so 00:16:04.840 --> 00:16:07.200 much? Because it's a trap. It looks behavioral. 00:16:07.299 --> 00:16:09.139 It looks like ADHD. It looks like a kid who's 00:16:09.139 --> 00:16:11.679 just not listening. So walk us through the differentiation. 00:16:12.059 --> 00:16:14.460 I'm a parent. My teacher says my kid isn't paying 00:16:14.460 --> 00:16:16.879 attention. How do I know it's not ADHD? Look 00:16:16.879 --> 00:16:20.740 at the interruption. In ADHD, the child is distracted. 00:16:21.039 --> 00:16:23.600 They're looking out the window fidgeting. If 00:16:23.600 --> 00:16:26.000 you call their name, they usually look at you, 00:16:26.080 --> 00:16:27.639 maybe with some annoyance. They're still there. 00:16:27.820 --> 00:16:30.379 They're present. In an absence seizure, the brain 00:16:30.379 --> 00:16:32.899 is offline. You can wave your hand in front of 00:16:32.899 --> 00:16:35.980 their face, and they won't blink. They're completely 00:16:35.980 --> 00:16:38.519 unaware of their surroundings. And physical signs? 00:16:38.620 --> 00:16:42.000 Are there any? Very subtle. You might see eyelid 00:16:42.000 --> 00:16:44.620 myoclonia, the eyelids fluttering or rolling 00:16:44.620 --> 00:16:47.580 back slightly, or maybe a tiny rhythmic smacking 00:16:47.580 --> 00:16:51.210 of the lips. But the key is the duration. It's 00:16:51.210 --> 00:16:55.509 short, five to 10 seconds. And then, snap, they 00:16:55.509 --> 00:16:59.149 are back. No postictal confusion. None. Zero. 00:16:59.710 --> 00:17:01.370 They pick the sentence exactly where they left 00:17:01.370 --> 00:17:04.150 off. They have no idea any time has passed. That's 00:17:04.150 --> 00:17:06.130 the hallmark. That feels like it would be incredibly 00:17:06.130 --> 00:17:07.849 hard to catch if you weren't looking for it. 00:17:08.069 --> 00:17:10.569 It is. Often these kids get diagnosed because 00:17:10.569 --> 00:17:13.430 their grades tank. They're missing 50 chunks 00:17:13.430 --> 00:17:16.049 of information a day. It's like watching a movie 00:17:16.049 --> 00:17:18.670 with a scratch DVD that keeps skipping scenes. 00:17:19.009 --> 00:17:21.339 You lose the plot. OK, let's move to the second 00:17:21.339 --> 00:17:23.640 big bucket, focal onset. We talked about the 00:17:23.640 --> 00:17:26.279 toggle switch. Let's start with focal with retain 00:17:26.279 --> 00:17:30.240 awareness. The child is awake. This is all about 00:17:30.240 --> 00:17:33.079 location, location, location. If the seizure 00:17:33.079 --> 00:17:35.420 is in the motor strip for the hand, the hand 00:17:35.420 --> 00:17:37.880 twitches. If it's in the sensory strip, they 00:17:37.880 --> 00:17:40.759 feel numbness or tingling. What about the temporal 00:17:40.759 --> 00:17:42.960 lobe? I've heard those can be weird. The temporal 00:17:42.960 --> 00:17:45.960 lobe handles memory and emotion. So a focal seizure 00:17:45.960 --> 00:17:49.599 there can cause psychic symptoms. sudden unexplainable 00:17:49.599 --> 00:17:53.140 fear, a wave of sadness, or deja vu, that feeling 00:17:53.140 --> 00:17:55.599 that I've been here before. It's a memory firing 00:17:55.599 --> 00:17:57.900 at the wrong time. And since they are awake, 00:17:58.140 --> 00:18:00.140 they can tell you. They can describe it. Mommy, 00:18:00.359 --> 00:18:03.039 the room looks small. Mommy, I smell rotten eggs. 00:18:03.400 --> 00:18:05.380 It's a sensory hallucination, but they know it's 00:18:05.380 --> 00:18:08.099 not real. They are observing their own brain's 00:18:08.099 --> 00:18:10.750 strange behavior. Now, if the toggle switch slides 00:18:10.750 --> 00:18:13.230 down focal with impaired awareness, this used 00:18:13.230 --> 00:18:15.630 to be called complex partial. This is the most 00:18:15.630 --> 00:18:17.930 common type of seizure in adults, but we see 00:18:17.930 --> 00:18:20.809 it in kids too. The consciousness is clouded, 00:18:20.970 --> 00:18:24.390 and this is where we see automatisms. What exactly 00:18:24.390 --> 00:18:27.130 is an automatism? It's an automatic, repetitive 00:18:27.130 --> 00:18:30.150 behavior that serves no purpose. Lips smacking, 00:18:30.670 --> 00:18:33.670 chewing, picking at the buttons on a shirt, rubbing 00:18:33.670 --> 00:18:36.210 the hands together, walking in circles. It sounds 00:18:36.210 --> 00:18:39.329 like fidgeting. or a nervous habit. It does. 00:18:39.849 --> 00:18:42.809 And in an infant, this is a nightmare to diagnose. 00:18:43.329 --> 00:18:45.369 Babies mack their lips all the time. They cycle 00:18:45.369 --> 00:18:47.769 their legs. They suck on their fists. It's normal 00:18:47.769 --> 00:18:50.450 behavior. So how do you tell, how do you differentiate 00:18:50.450 --> 00:18:53.210 normal baby stuff from a seizure? You try to 00:18:53.210 --> 00:18:55.930 interrupt it. If a baby is just playing or self 00:18:55.930 --> 00:18:58.789 -soothing and you gently hold their hands, they 00:18:58.789 --> 00:19:01.059 will look at you and stop. they'll react to you. 00:19:01.539 --> 00:19:03.400 If it's a seizure, the movement will continue, 00:19:03.740 --> 00:19:05.500 or they will fight against the restraint with 00:19:05.500 --> 00:19:08.420 a rhythmic, unnatural force, and they won't make 00:19:08.420 --> 00:19:10.079 eye contact. They'll look right through you. 00:19:10.200 --> 00:19:12.380 That's a huge clinical pearl. Can I interrupt 00:19:12.380 --> 00:19:14.460 that? Exactly. If you can stop it with a gentle 00:19:14.460 --> 00:19:17.220 touch or distract them, it's probably not a seizure. 00:19:17.660 --> 00:19:20.279 Now, we need to talk about the emergencies, the 00:19:20.279 --> 00:19:23.619 monsters. Section four, status epilepticus. This 00:19:23.619 --> 00:19:25.940 is the code blue of neurology. This is the one 00:19:25.940 --> 00:19:28.829 you have to act on, fast. What is the official 00:19:28.829 --> 00:19:31.089 definition? Because I feel like it's changed. 00:19:31.369 --> 00:19:33.769 It has. It used to be a seizure lasting 30 minutes. 00:19:34.549 --> 00:19:36.789 But we realized that if we wait 30 minutes, the 00:19:36.789 --> 00:19:39.430 brain is already cooked. So the operational definition 00:19:39.430 --> 00:19:42.069 now is a seizure lasting longer than five minutes, 00:19:42.730 --> 00:19:45.390 or repeated seizures, where the patient doesn't 00:19:45.390 --> 00:19:47.630 wake up in between. So if a child has a seizure, 00:19:48.369 --> 00:19:50.589 stops, and then starts another one two minutes 00:19:50.589 --> 00:19:52.910 later without ever waking up. That's status. 00:19:53.210 --> 00:19:55.750 You start the clock, and you don't stop it until 00:19:55.750 --> 00:19:57.789 they are back to their baseline consciousness. 00:19:58.130 --> 00:20:00.589 Why is time such a critical factor here? What's 00:20:00.589 --> 00:20:02.670 happening in the brain? Think about the electrical 00:20:02.670 --> 00:20:06.109 grid again. If you run the grid at 500 % capacity 00:20:06.109 --> 00:20:08.930 for a sustained period, the wires melt. During 00:20:08.930 --> 00:20:11.690 a seizure, the brain's metabolic rate skyrockets. 00:20:11.930 --> 00:20:14.809 It is devouring oxygen and glucose at an insane 00:20:14.809 --> 00:20:17.490 rate. So the brain is starving. Starving, and 00:20:17.490 --> 00:20:20.309 it's frying. After about five minutes, the body's 00:20:20.309 --> 00:20:23.099 compensatory mechanisms fail. You get hypoxia, 00:20:23.200 --> 00:20:25.700 which is low oxygen. You get hypoglycemia, low 00:20:25.700 --> 00:20:29.220 sugar. And eventually, neurons start dying. Permanent 00:20:29.220 --> 00:20:31.819 brain damage. OK, so I'm the nurse. I look at 00:20:31.819 --> 00:20:33.700 my watch. It's been six minutes. The seizure 00:20:33.700 --> 00:20:37.500 is not stopping. What is the priority? ABCs. 00:20:38.079 --> 00:20:41.660 Airway breathing circulation. Always. If they 00:20:41.660 --> 00:20:43.359 aren't breathing, you bag them. You get oxygen 00:20:43.359 --> 00:20:45.420 on them. You make sure they have a pulse. And 00:20:45.420 --> 00:20:47.940 then drugs? You need to stop the electrical storm. 00:20:48.220 --> 00:20:51.039 The first line of defense is benzodiazepines, 00:20:51.259 --> 00:20:53.519 lorazepam, which is adipon, or diazepam, which 00:20:53.519 --> 00:20:56.039 is valium. How are those given? Often given ifedi 00:20:56.039 --> 00:20:58.240 if you can get a line in a seizing child, which 00:20:58.240 --> 00:21:01.359 is hard. So there are other roads. Rectal diazepam 00:21:01.359 --> 00:21:04.099 is very common for home use. Intranasal metazolem 00:21:04.099 --> 00:21:07.059 is also an option. Why benzos? They are the emergency 00:21:07.059 --> 00:21:09.799 stop button. They work fast to flood the brain 00:21:09.799 --> 00:21:12.130 with inhibitory signals. basically telling the 00:21:12.130 --> 00:21:14.750 neurons to calm down, but they wear off fast. 00:21:15.089 --> 00:21:16.829 So you can't just give adage on and walk away. 00:21:16.930 --> 00:21:19.829 You need a backup, a long -term plan. You need 00:21:19.829 --> 00:21:22.470 a maintenance drug, something long -acting, to 00:21:22.470 --> 00:21:25.049 keep the seizure from coming back. That's usually 00:21:25.049 --> 00:21:28.329 phosphinitoin or phenobarbital. So stop it with 00:21:28.329 --> 00:21:30.569 benzos. Keep it stopped with phenitoin. Correct. 00:21:30.730 --> 00:21:33.109 And while you are doing that, check the glucose. 00:21:33.750 --> 00:21:35.849 Get a finger stick. Because the brain ate it 00:21:35.849 --> 00:21:38.980 all. Exactly. or because low blood sugar caused 00:21:38.980 --> 00:21:41.059 the seizure in the first place. If the glucose 00:21:41.059 --> 00:21:43.819 is 20, all the Ativan in the world won't fix 00:21:43.819 --> 00:21:46.140 it. You need dextrose. You have to treat the 00:21:46.140 --> 00:21:49.700 cause. Got it. Now the final specific type. This 00:21:49.700 --> 00:21:52.359 one was listed under unknown onset in the notes, 00:21:52.579 --> 00:21:55.579 but you flagged it as a developmental emergency. 00:21:56.039 --> 00:21:58.799 Infantile spasms. West syndrome? This is the 00:21:58.799 --> 00:22:00.619 one that pediatricians are terrified of missing. 00:22:00.720 --> 00:22:03.539 Who gets this? What's the age range? Babies. 00:22:03.839 --> 00:22:07.609 Yeah. Usually 3 to 12 months old. The peak is 00:22:07.609 --> 00:22:09.809 around four to six months. It's rare to see it 00:22:09.809 --> 00:22:11.650 start after 18 months. And what does it look 00:22:11.650 --> 00:22:13.130 like? It doesn't look like a grand mal, right? 00:22:13.329 --> 00:22:15.730 Not at all. It looks like a jackknife. Imagine 00:22:15.730 --> 00:22:18.430 the baby is lying on their back. Suddenly their 00:22:18.430 --> 00:22:20.690 head crunches forward, knees come up to their 00:22:20.690 --> 00:22:23.609 chest, and arms fling out to the side. It's a 00:22:23.609 --> 00:22:26.049 sudden flex. It's like a crunch exercise at the 00:22:26.049 --> 00:22:28.769 gym. Exactly. And it happens in clusters. Crunch. 00:22:29.359 --> 00:22:32.339 Relax, crunch, relax. It might happen 20, 50, 00:22:32.579 --> 00:22:35.000 100 times in a row, often right after they wake 00:22:35.000 --> 00:22:36.759 up in the morning or from a nap. And the parents 00:22:36.759 --> 00:22:39.519 think it's colic or startle reflex. They think 00:22:39.519 --> 00:22:41.819 it's a tummy ache. Oh, he's pulling his legs 00:22:41.819 --> 00:22:44.660 up. He must have gas. Or they think it's just 00:22:44.660 --> 00:22:47.880 the moro reflex, but it's rhythmic and clustered, 00:22:48.140 --> 00:22:50.579 which is the key difference. Why is this an emergency? 00:22:50.799 --> 00:22:52.900 It sounds, I mean, it sounds relatively mild 00:22:52.900 --> 00:22:55.240 compared to the shaking of a tonic clonic. The 00:22:55.240 --> 00:22:57.809 seizure looks mild. The consequence is devastating. 00:22:58.589 --> 00:23:02.029 Infantile spasms are a sign of a chaotic, disorganized 00:23:02.029 --> 00:23:04.789 brainwave pattern called hypsarrhythmia. It's 00:23:04.789 --> 00:23:07.970 electrical chaos. If you don't stop it, the brain 00:23:07.970 --> 00:23:11.309 stops developing. Stop. Stops and often regresses. 00:23:11.789 --> 00:23:13.769 The baby who is smiling and cooing and rolling 00:23:13.769 --> 00:23:16.910 over suddenly stops smiling, stops rolling. If 00:23:16.910 --> 00:23:19.410 you miss this diagnosis for a month or two, that 00:23:19.410 --> 00:23:22.480 child may never recover those milestones. Severe 00:23:22.480 --> 00:23:24.740 cognitive disability is the outcome. So if a 00:23:24.740 --> 00:23:26.579 parent describes rhythmic crunching in their 00:23:26.579 --> 00:23:29.759 baby... You order an EEG immediately. Do not 00:23:29.759 --> 00:23:32.480 wait. This is a time of brain situation. Just 00:23:32.480 --> 00:23:34.920 like a stroke. And the treatment? Is it the same 00:23:34.920 --> 00:23:37.539 as other seizures? It's weirdly specific. It's 00:23:37.539 --> 00:23:40.700 not standard seizure meds like Keppra or phenobarbital. 00:23:41.000 --> 00:23:45.200 We use ACTH, adrenocorticotropic hormone. It's 00:23:45.200 --> 00:23:48.319 a steroid injection. Or a medication called vigabatrin. 00:23:48.839 --> 00:23:50.779 But you need a pediatric neurologist and you 00:23:50.779 --> 00:23:53.970 need one now. Wow. Okay, that is a heavy list. 00:23:54.230 --> 00:23:56.009 But I feel like I can see the differences now. 00:23:56.369 --> 00:23:59.190 I want to move to section C, comparison tables. 00:23:59.650 --> 00:24:02.089 Let's synthesize this. If we're building a cheat 00:24:02.089 --> 00:24:04.930 sheet for the exam, let's visualize the Prostictal 00:24:04.930 --> 00:24:07.329 State column. Great idea. The Aftermath column. 00:24:07.630 --> 00:24:09.269 This is a huge differentiator. Okay, so let's 00:24:09.269 --> 00:24:11.970 run through them. Absent seizure. Prosticle state. 00:24:12.589 --> 00:24:14.549 None. Immediate return to baseline. It's like 00:24:14.549 --> 00:24:16.630 a light switch flipping off and on. Ponticlonic. 00:24:16.869 --> 00:24:20.000 Prosticle state. Severe. Deep sleep, confusion, 00:24:20.200 --> 00:24:22.740 amnesia, muscle soreness, headache, can last 00:24:22.740 --> 00:24:25.779 for hours. Focal with retained awareness. Postictal 00:24:25.779 --> 00:24:28.160 state, none. They were awake the whole time. 00:24:28.460 --> 00:24:29.980 They might be tired or scared, but they're not 00:24:29.980 --> 00:24:31.779 confused. Then focal with impaired awareness, 00:24:31.819 --> 00:24:34.519 the one with the automatisms. Postictal state, 00:24:35.740 --> 00:24:39.059 mild confusion. They might feel groggy or disoriented 00:24:39.059 --> 00:24:41.380 for a few minutes, but they are not comatose 00:24:41.380 --> 00:24:44.400 like the toniclonic. They kind of come to and 00:24:44.400 --> 00:24:47.000 wonder where they are. That is extremely helpful 00:24:47.000 --> 00:24:50.000 for differentiating. Now, let's do a safety priority 00:24:50.000 --> 00:24:52.119 column. What's the number one thing to worry 00:24:52.119 --> 00:24:54.640 about for each? Okay, let's do it. Tonic, conic. 00:24:55.079 --> 00:24:58.680 Priority. Airway and physical protection. Sidelying, 00:24:58.900 --> 00:25:02.400 clear the area, cushion the head. Atonic. Priority. 00:25:02.700 --> 00:25:05.839 Head protection, helmet, supervision during walking, 00:25:06.119 --> 00:25:08.460 especially on stairs, preventing trauma from 00:25:08.460 --> 00:25:11.509 the fall. Status epilepticus. Priority. Life 00:25:11.509 --> 00:25:15.309 support, ABCs, oxygen, glucose, 5e access, stop 00:25:15.309 --> 00:25:17.589 the seizure with meds. It's a medical rescue. 00:25:17.690 --> 00:25:19.829 Aims and tiles, bathroom. Priority, developmental 00:25:19.829 --> 00:25:21.849 preservation. The emergency isn't the seizure 00:25:21.849 --> 00:25:24.210 itself, it's getting the diagnosis. Immediate 00:25:24.210 --> 00:25:26.190 referral and diagnosis to save the brain. It 00:25:26.190 --> 00:25:27.950 really is a map. Once you know what you're dealing 00:25:27.950 --> 00:25:30.150 with, the priority highlights itself. Exactly. 00:25:30.210 --> 00:25:32.509 The diagnosis dictates the action. Let's move 00:25:32.509 --> 00:25:35.089 to section D, exam strategy and nursing management. 00:25:35.490 --> 00:25:38.849 You called yourself an NCLEX coach. Why do exam 00:25:38.849 --> 00:25:41.519 writers love this topic so much? Because it tests 00:25:41.519 --> 00:25:44.480 everything. One question about a seizure tests 00:25:44.480 --> 00:25:47.039 your knowledge of anatomy, your safety instincts, 00:25:47.440 --> 00:25:50.059 your prioritization skills, and your pharmacology 00:25:50.059 --> 00:25:52.519 knowledge. It's an incredibly high -yield topic. 00:25:52.740 --> 00:25:55.259 Okay, so let's talk about the traps, the distractors. 00:25:55.480 --> 00:25:58.559 We mentioned the tongue blade. If you see padded 00:25:58.559 --> 00:26:02.660 tongue blade or insert oral airway during an 00:26:02.660 --> 00:26:05.779 active tonic -clonic seizure, eliminate that 00:26:05.779 --> 00:26:08.839 option immediately. It is always wrong. You will 00:26:08.839 --> 00:26:11.910 cause more harm. What about restraints? The option 00:26:11.910 --> 00:26:14.250 that says something like gently restrain the 00:26:14.250 --> 00:26:17.390 limbs. Hold the child's hands to prevent flailing. 00:26:18.170 --> 00:26:20.650 Wrong. You will cause injury. You never fight 00:26:20.650 --> 00:26:22.890 the seizure. What about go get help? That seems 00:26:22.890 --> 00:26:25.569 like a good idea. Careful. The wording is key. 00:26:26.130 --> 00:26:28.349 If the option is leave the room to find a doctor, 00:26:28.410 --> 00:26:30.450 that's usually wrong. You never leave the patient 00:26:30.450 --> 00:26:32.730 alone during a seizure. So what do you do? You 00:26:32.730 --> 00:26:34.910 yell for help, you hit the call bell, but you 00:26:34.910 --> 00:26:36.910 stay at the bedside to monitor the airway and 00:26:36.910 --> 00:26:39.210 time the event. Your first action is to ensure 00:26:39.210 --> 00:26:42.329 safety. not to abandon the patient. Timing. We 00:26:42.329 --> 00:26:43.930 haven't stressed that enough. Why is the nurse 00:26:43.930 --> 00:26:46.230 looking at their watch? Because the doctor isn't 00:26:46.230 --> 00:26:48.450 there. You are the eyes and ears of the medical 00:26:48.450 --> 00:26:51.170 team. The difference between a two -minute seizure 00:26:51.170 --> 00:26:54.170 and a six -minute seizure determines if we give 00:26:54.170 --> 00:26:56.869 emergency drugs. It's the status epilepticus 00:26:56.869 --> 00:26:59.329 trigger. It is. And the difference between started 00:26:59.329 --> 00:27:01.990 in the right hand and started all over determines 00:27:01.990 --> 00:27:05.049 the diagnosis focal versus generalized. Your 00:27:05.049 --> 00:27:07.369 documentation is the diagnosis in many cases. 00:27:07.559 --> 00:27:10.279 Let's touch on family education. Fibral seizures 00:27:10.279 --> 00:27:12.740 versus epilepsy. Parents must be losing their 00:27:12.740 --> 00:27:16.319 minds. This is a huge source of anxiety. A fibral 00:27:16.319 --> 00:27:18.700 seizure happens because of a rapid spike in temperature 00:27:18.700 --> 00:27:21.279 in a young child, usually between six months 00:27:21.279 --> 00:27:24.480 and five years of age. Is it epilepsy? No. By 00:27:24.480 --> 00:27:26.599 definition, it's not. It does not mean the child 00:27:26.599 --> 00:27:28.599 has epilepsy. It does not mean they have brain 00:27:28.599 --> 00:27:31.380 damage. It's a reaction of an immature brain 00:27:31.380 --> 00:27:33.980 to the fever. So what do we tell the terrified 00:27:33.980 --> 00:27:36.759 parents? We reassure them. We treat the fever 00:27:36.759 --> 00:27:39.420 with antipyretics like acetaminophen or ibuprofen. 00:27:39.720 --> 00:27:42.160 We tell them it's likely benign, but we teach 00:27:42.160 --> 00:27:44.460 them seizure safety just in case it happens again. 00:27:44.720 --> 00:27:46.839 However, we distinguish that from unprovoked 00:27:46.839 --> 00:27:49.039 seizures, which are seizures without a fever. 00:27:49.579 --> 00:27:52.599 Those require a full neurologic workup. And for 00:27:52.599 --> 00:27:55.299 the child with known epilepsy, the school -age 00:27:55.299 --> 00:27:57.660 kid, what about seizure precautions at home? 00:27:57.660 --> 00:28:00.200 What's practical? It's about balance. We don't 00:28:00.200 --> 00:28:03.009 want to wrap them in bubble wrap. But water is 00:28:03.009 --> 00:28:06.849 a major risk. Showers are safer than baths. If 00:28:06.849 --> 00:28:08.789 they have a seizure in a bath, they can drown 00:28:08.789 --> 00:28:11.430 silently. And swimming. Only with one -on -one 00:28:11.430 --> 00:28:13.690 supervision. Someone whose only job is to watch 00:28:13.690 --> 00:28:17.250 that child. And heights, like bunk beds or climbing 00:28:17.250 --> 00:28:19.829 trees. Padded side rails on the bed can be helpful. 00:28:20.109 --> 00:28:22.630 Maybe the bottom bunk is a better idea. And for 00:28:22.630 --> 00:28:24.970 climbing, it's a risk assessment. How frequent 00:28:24.970 --> 00:28:27.289 and severe are the seizures? It's about empowering 00:28:27.289 --> 00:28:30.720 the family to make reasonable, not fearful. decisions. 00:28:30.940 --> 00:28:33.000 This has been incredibly clarifying. Let's head 00:28:33.000 --> 00:28:35.200 to the outro. Let's bring it home. We've covered 00:28:35.200 --> 00:28:37.880 a massive amount of ground, from the electrical 00:28:37.880 --> 00:28:40.759 grid to the jackknife spasm. If the listener 00:28:40.759 --> 00:28:43.460 takes away just three things from this whole 00:28:43.460 --> 00:28:46.200 deep dive, the big three, what should they be? 00:28:46.480 --> 00:28:50.339 Number one, safety first. Your primary job is 00:28:50.339 --> 00:28:52.539 not to stop the seizure with your bare hands, 00:28:52.980 --> 00:28:54.480 it's to protect the patient from the environment 00:28:54.480 --> 00:28:57.759 and protect their airway. Sideline, no restraints, 00:28:57.859 --> 00:28:59.950 nothing in the mouth. Protect the head. Number 00:28:59.950 --> 00:29:04.009 two. Know your if -then patterns. If they're 00:29:04.009 --> 00:29:06.509 staring and snap back the absence, if they drop 00:29:06.509 --> 00:29:08.809 like a stone a tonic, if they are a baby doing 00:29:08.809 --> 00:29:11.789 rhythmic crunches and infantile spasms, classification 00:29:11.789 --> 00:29:14.210 dictates treatment and priority. And number three. 00:29:14.470 --> 00:29:17.069 Respect the emergencies. Status epilepticus is 00:29:17.069 --> 00:29:19.750 a metabolic fire that burns the brain. Inventile 00:29:19.750 --> 00:29:21.990 spasms are a developmental wall that stops growth. 00:29:22.309 --> 00:29:24.369 You have to move fast on those. Time is brain. 00:29:24.490 --> 00:29:26.390 I want to leave everyone with one final thought. 00:29:26.539 --> 00:29:28.660 We spend so much time focusing on the seizure 00:29:28.660 --> 00:29:31.319 itself, the dramatic event, the shaking, the 00:29:31.319 --> 00:29:33.839 fall, but I keep thinking about the postictal 00:29:33.839 --> 00:29:35.559 phase. It's the invisible part of the illness. 00:29:35.660 --> 00:29:37.980 It's the part no one sees. Imagine a 10 -year 00:29:37.980 --> 00:29:40.819 -old girl. She has a tonic -clonic seizure at 00:29:40.819 --> 00:29:44.400 7 a .m. She's technically recovered by 8 a .m., 00:29:44.400 --> 00:29:47.839 but her brain is in a fog until noon. She goes 00:29:47.839 --> 00:29:50.519 to school, but she can't process math. She feels 00:29:50.519 --> 00:29:53.119 slow. She feels stupid. The teacher thinks she's 00:29:53.119 --> 00:29:55.779 not trying. And if she has nocturnal seizures? 00:29:56.329 --> 00:29:59.089 Seizure's in her sleep. She wakes up exhausted 00:29:59.089 --> 00:30:01.230 every single day with a headache, and she doesn't 00:30:01.230 --> 00:30:04.349 even know why. Exactly. We judge these kids on 00:30:04.349 --> 00:30:06.829 their behavior or their grades, but we forget 00:30:06.829 --> 00:30:10.309 the physiological toll of the recovery. The safety 00:30:10.309 --> 00:30:12.470 brain isn't just for the five minutes of the 00:30:12.470 --> 00:30:14.970 seizure, it's for understanding the whole child 00:30:14.970 --> 00:30:18.130 the whole 24 -hour day. That is beautifully said. 00:30:18.250 --> 00:30:20.569 It's holistic care. It's seeing beyond the event. 00:30:20.609 --> 00:30:22.390 Thank you so much for guiding us through the 00:30:22.390 --> 00:30:25.049 map. To the learner listening, you now have the 00:30:25.049 --> 00:30:27.759 grid. You know where the Transformers are, go 00:30:27.759 --> 00:30:30.400 crush the NCLE -X, and more importantly, go be 00:30:30.400 --> 00:30:32.180 the calmest person in the room when the storm 00:30:32.180 --> 00:30:34.500 hits. You've got this. Thanks for listening to 00:30:34.500 --> 00:30:35.859 the Deep Dive. Catch you next time.