Non Convulsive Status Epilepticus with Dr. Roderick Fontenette

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Hello, I'm Captain Matthew Turner, and welcome to another

episode of the GSA SEP podcast. In this episode, we discuss

nonconvulsive status epilepticus with Dr. Roderick Fonnet. Dr.

Fontnet is a board-certified EM and critical care medicine

physician. He attended medical school at Louisiana State

University Health Sciences Center. He completed EM

residency training at Wright-Patterson Air Force Base

and critical care fellowship training with Indiana

University. Afterwards, he completed his Master of

Healthcare Management from the Harvard T.H. Chan School of

Public Health. His most recent Air Force assignment was as the

associate program director for one of the Air Force's four

emergency medicine residency programs partnered with UC Davis

Medical Center Department of Emergency Medicine. Dr. Fonant

recently retired from the Air Force after serving 21 years on

active duty. During his time on active duty, he completed

several deployments to locations such as Afghanistan, Djibouti,

Kuwait, Turkey, and Germany, where he provided critical care

transport, he served as the critical care air transport team

theater director during the Afghanistan drawdown, and

provided high acuity transport for joint and international

forces. He now works as the medical director of the ICU at

St. Helena Hospital in the Napa Valley, and does academic

emergency medicine at UC Davis Medical Center. He has lectured

nationally and internationally on a wide range of emergency

medicine and critical care medicine topics, and has an

interest in neurologic emergencies and resuscitative

medicine. For listeners who may not frequently encounter it,

what exactly is nonconvulsive status epilepticus?

Yeah, so great question, right? And so I think to most of us,

and definitely to like the general population, when we

think about seizures, we think about like GTCs, right? Just

general tonic-clonic seizures that I can see from across the

room, and I can tell you that patient is probably seizing just

because of the convulsions, right? So what non-convulsive

seizures are is just that: is that the patient is still having

electrographic seizures, but outwardly and physical

exam-wise, I just you just can't pick up the seizures. Now

sometimes they may have like a little tremor of the thumb or

whatever the case may be, but again, man, in busy emergency

departments and busy like intensive care units and around

the hospital and definitely in a deployed environment, you're not

going to pick that up, right? It's just way too much going on.

These little subtleties, you're just not going to see them. And

so, with non-convulsive seizures, always that at times

convulsive seizures, if not either one caught soon enough

and/or two managed appropriately, those convulsive

seizures will burn out and become non-convulsive seizures.

Again, unless you check, you just won't know, and that's I

think what what makes the prevalence so difficult to know

for certain, right? And like the incidents, how often does this

occur in an emergency department? It makes it tough to

know for sure because unless you have some way of monitoring and

checking, you just don't know. And so it's it's a tough one to

diagnose because quite often we'll get those patients that

come in in an emergency department setting with the like

undifferentiated altered mental status or depressed mental

status that I just don't know why they're suppressed, and

we're going to kind of run through all of our toxic

metabolic head CTs. This is a space occupying lesion. We're

going to do that full workup, but non convulsive status still

has to be on our differential, and I remember one day I was

doing a talk in on nonconvulsive status, and one of the docs it

was to an ED group, and one of the docs says, "Well, I don't

think I've ever missed a nonconvulsive seizure, but then

at that same time, they don't have a way to monitor those,

right? I was like, "That's like saying I've never missed a

STEMI, but I've never done an EKG. It's like that just doesn't

compute, right? That math ain't mathing, and so you won't know

the true incidence of how often you're missing it if you don't

have a way to check. And I think that oftentimes becomes the lim

fact for most of us in small, like community hospitals, is

that I don't have 24/7 access to continuous or conventional EEGs,

and even in some of these larger institutions, you may. Have

access to it, but after hours and definitely on the weekends,

that access may not be so readily available, and so that's

where we kind of run into issues.

That's a scary thing thinking about how often we're missing

it. How common would you say non-convulsive status is in

emergency departments? Do we have any sort of idea at all?

Yeah, so I've seen some studies where it says as low as 5% to as

high as like 35% right? And so whenever I see like those big

gaps, it always makes me be like, "That's weird, right? But

again, and I think the reason why you see that that wide range

is because it's I think is significantly underreported

because it is significantly under checked for and under

tested for because again we don't have access to a lot of a

lot of the true like either one conventional EEGs or point of

care EEGs. There are several companies that have come out

that kind of lead in that space. And for full disclosure, I am a

paid spokesperson for one of those companies. But

nonetheless, true point of care EEG, which I can have a device

on within minutes, I can have a read within minutes without

having to call in an EEG tech. Don't have to call in an

epileptologist at bedside to read. Those things have helped,

I think, to really shorten and close that gap. But again,

unless you have access to to some form of neural monitoring,

the incidence I think is going to be kind of hard to know for

certain, because a lot of us just can't test. When you talk

about like the incidents, one thing I would like to say though

is that it has also been reported that about 92% seizures

that happens in a critical care setting are non-convulsive.

That's a problem, right? And so I know you could say, well, I

mean, for most of our listeners, it's going to be like emergency

department folks, but I don't know about in your place, but in

a lot of places that I work, boarding is a problem. And if

boarding is a problem, yes, that patient may have orders to go to

the ICU, but that ICU patient is going to hang out with me for a

while in the ED. So I don't think that geography should

determine the level of care that this patient is being provided.

That patient that is still altered, still going to the ICU,

just because they're physically in the ED, that doesn't mean

that they have to wait until they're upstairs in an ICU bed

to get EEG monitoring. Because again, that patient can board

with us for many, many hours while they're in the ED. Also, a

lot of us that work in these smaller hospitals, that patient,

yeah, they may physically go to an ICU bed, but the ED doc is

still kind of monitoring and managing a lot of that stuff,

right? We respond to the codes upstairs and all of that. Does

that mean that that patient now that is altered, sitting

upstairs in that ICU bed, waiting for the day shift team

to comes in to come in? That patient is just going to be

seizing all night because I don't have a way to know if

they're seizing. I mean, so it's it's it's all of these things

that we have to consider. So again, up to 92% of patients in

an ICU setting that are having seizures are non-convulsive

seizures. Again, we just don't know because we're not testing.

So that's a problem. That's a big problem. Right. Another

number I like to always throw out is that again starts with us

quite often in the emergency department. Is those patients

post Rosk, right? They come in, we have high fiving because we

got Ross back. That patient now again is still hanging out with

us in the ED, waiting on the bed to go upstairs. As high as a

third of those patients post Rosk are having nonconvulsive

seizures. You don't know if you ain't checking, right? And so

then I put my intensivist hat on. That concerns me because you

have to wonder how many of those patients have you had goes of

care conversations with post Ross, and it's like, look,

Granny's just not waking up because I think she has a pretty

profound anoxic brain injury, but she's really just in non

convulsive status. Again, we don't know because we don't

check, and so you have to check. And non-convulsive seizures,

again, I think is way more prevalent. We just don't know

because we don't just don't test often enough for it.

And if you look at the 2020 AHA guidelines, it says specifically

in all patients post Ros that have not returned back to their

baseline, they are strongly recommending getting an EEG on

those patients, neurocritical care society is recommending

getting an EEG within 15 to 60 minutes. You're not going to get

that in a small ED or even in a small hospital at one in the

morning. There's just there's no way of getting an EEG on that

patient within 60 minutes. It's not happening with a

conventional EEG, and so that's what we have to start thinking.

Maybe we need to look at some of these true point of care EEG

devices, bringing them to the bedside to get data sooner

rather than later.

Wow, I had no idea that the prevalence of this was so high.

Are there any specific examination findings that

emergency physicians should actively look for in these

cases?

Yeah, great question. Right, so sometimes you may get like an

eye deviation on some of these folks that may kind of increase

your index of suspicion. For instance, in the ICU that I work

at here, I'm the medical director of the intensive care

unit in Saint Helena, which is in the lovely Napa Valley, and

we do a ton of cardiac cases, right? Valves, cabbages, like we

do all the things, and so we do ECMO, we do all that here,

right, and so. I had a lady that came out. I think she was in her

70s. Had just a regular, like, routine three-vessel cabbage.

Parked in the ICU, and we usually try to extubate these

folks within six hours, right? So it's called fast track

extubation. That's kind of what most folks try to do that have

these cardiac programs. And so sedation was off around hour two

or so. So I got and settled in the room from the ward. Nurses

started to come down on sedation. Now sedation is off

because we are now actively trying to wake you up. And the

nurse called me and was like, "Hey, you know, she kind of has

like her eyes are kind of like deviated, kind of like to the

right. No outward obvious signs of like GTCs or obvious seizing.

She's like, but she's kind of I don't know. Do you mind if we

put on like the point of care seizure device, I was like,

"Yeah, go for it, and I'm on my way. Like my office is literally

just on the other side to the ICU, so I got there, and sure

enough, dude, she was seizing nonconvulsive status. Now,

usually, I would have said like, without a device to know for

certain, or without being able to check like immediately, I'd

have said, "Oh, it's just the anesthesia, right? She's a bit

older. She has to metabolize anesthesia. That's why she's not

waking up. Well, when she didn't wake up about another hour or

two later, I'd say, you know what? Let's send her down for a

head CT because she got heparin and she was on pump and all this

other stuff. Maybe it's just pump brain, but nonetheless,

let's send her down, get an icon, head CT. That would have

been negative. Okay, tomorrow then, if she's not waking up,

let's get an MRI. That MRI tomorrow would have been

negative because now I'm concerned because she have a

stroke, right? Am I just missing a stroke that the head CT might

have been a little bit too soon on and we missed it? Okay, so

tomorrow she gets an MRI. MRI is unremarkable, right? Another day

or so, she still ain't waking up, right? And so you see how

this works, and so that whole time though, she's a

non-convulsive seizures that I just I haven't caught, I haven't

that I'm missing, right? And so the longer these patients seize,

the less effective our therapeutics are. Meaning, like

usually for most of us, first lines could be benzos, and then

the longer they seize, the mortality begins to go up. And

so now she may be recovering just fine from a three vessel

cabbage. Now her brain is offline because I've missed non

convulsive seizures this whole time, and so, and that's a

problem. And she had absolutely no history of seizures, and so

that wouldn't have been as high on my differential because why

would she seize when I don't? I don't think she has a history of

it. But again, I don't know unless I go looking for it. I

have to go looking for it, and so, and that saved me. I was

able to safely. I treated the seizure. I called neurology. She

did not require anti like long term anti seizure medications,

and then I was able to safely get her extubated the next day.

And she's already been out of the hospital onto a meeting for

recovery. And so that's what thinking about seizures for

looking for some of these subtle findings, like the eye. Her eyes

were twitching to the left. That's what alerted the nurse to

say, "Hey, look, I think we need to go looking.

And so the nurse is the one that actually I think did the the

great exam, got the abnormal finding, was able to alert me,

and then that led to a whole sequence of other other events

that allowed us to then get her timely care and get her the

appropriate care. And again, now she's out of the hospital onto

recovery. But we never would have caught that had the nurse

not going looking for it and bringing it to my attention. So

yeah, so sometimes again the eyes can rove to one side or the

other. Again, you may get like a subtle, like thumb or finger

twitching that you may be able to pick up. But again, man, it's

it is so hard with some of these folks to truly know if they're

seizing. If not, should have just been undifferentiated

altered mental status, and I don't know why she's not waking

up. And then that leads to a whole casket of things we do for

the typical like altered mental Status patient

besides EEG or point of care EEG, is there really any way to

really distinguish nonconvulsive status from other issues like

stroke, delirium, medications, that sort of thing?

No, like so. There's some devices that are coming out.

Like I said, the one that I speak for, the one that that it

looks for like delirium, right, and kind of help because

sometimes you can say all the patients is delirious,

especially for us in the ICU, right? They can get some of this

ICU delirium. The longer they've been here, some of the

medications that we may use, you say, oh, they're just they're

just ICU ICU delirium, and that's why they're not waking

up. But what that point of care device is showing is that in

some of those patients that are actually having like ectal inner

ecto periods, and that's why they ain't delirious; they're

altered, right? Because of the seizures that they're having,

and so and that test, the point of care device helps us to be

able to detect that sooner rather than later. But again, we

have to go looking, and that's I think the biggest takeaway is

that you have to go looking.

Oh, absolutely. So once we suspect non-convulsive status

epilepticus, sounds like first priority. We go looking, get an

EEG or point of care device. What sort of medication

algorithm do you like to follow in these cases?

Yeah, great question. So then I just treat them as I would for

any other GTC, right? So usually benzod is going to be our first

choice, whether that's lorazomadaza, right? Lorazepam

had been on a shortage for a while, and so midazolam works

just fine. My thought, my my biggest takeaway on medications,

though, is that if you're going to use like lorazepam or any of

them, but specifically lorazepam, that is appropriately

dosed, right? So studies show that we underdose these patients

quite often, right? Remember, Loras is .1 mix for kegs max of

four milligrams. We repeated time a second dose at about like

three to five minutes later. If that did not break the seizure,

quite often that one to two milligrams of Loras that we're

giving that ain't go do it for most like normal size adults. So

you're under dosing them, which then leads to increased

likelihood that they're going to continue to seize. And so you

gotta break that seizure with the appropriate dose upfront,

and if that ain't working, man, I'm moving pretty quickly on to

a second agent, and so usually it's like benzo. Wait three to

five minutes, benzo. If I'm calling for that second dose of

benzo, I'm also calling for that second line agent. And again, if

you look at the the acid trial, it shows that there's really it

looked at phosphiny, vaproic acid, and levoteracetam or

kepra, and it showed that they all pretty much sucked about the

same. So they're each about 50% at breaking a seizure. So it's

pick one and go with it. I think most of us are going to lean on

levoteracetam or kepra for that second line agent because it's

one that we're probably most familiar with. Doesn't have

really a ton of medication interactions, and so we're going

to go with that. But that goes back to the earlier point I

if you're going to choose one, use the correct dose. That

one gram, two grams of Keppra for most folks ain't enough

Keppra. If you look at that study, in my mind, I remember

2040, 60, and so for phosphiny, it's 20 phenytoin equivalents

per kilo. I'm going to use valproic acid, it's 40 per kilo,

and if you're gonna use Keppra, is 60 per kilo, right? So 2040,

60. The max dose of Keppra of like four to four and a half

grams, and so two grams of Keppra in a most normal sized

adults probably won't be enough. And I think a lot of our

neurologists now are starting to push that, right? It's like how

much capper did you give? I gave a gram of capra. They say, you

know what? Let's give a total of four grams of capra. So let's

give another three grams to to include that one that you've

given, right? And so just have to make sure that we are

appropriately dosing those folks. And so again, first line

agent most of the time for me is going to be lorazepam. So I'd

say 0.1 makes with cake. So I'd say let's give four of loraz. If

they are still seizing, then I'll give another four, and I

said, okay, let's also load with 60 per kilo of Keppra. If you

get my second dose of Benzo, you are also getting a second line

agent, because what I know is that the likelihood of that

patient responding to that second line agent is about 10%

or less. And so, if you're going to give them a second line agent

because they are still seizing, just know it is likely that that

ain't going to work. You're probably going to have to make

it to your third line agent, and that's when we start talking

about securing the airway. Because I'm probably going to

want to put you on propofol. It's cappro now a good option,

right? So it's all these other things. Am I going to put you

just on a midazolam infusion? So all these things we're starting

to think about if we're going to have to make our way to the

third line agent, but usually, by the time I get to that third

line agent, I'm getting ready to intubate and just take over the

airway, just take over the scene, the the whole thing.

One point that I want to point to, though, if you're going to

intubate, going to sedate, that doesn't necessarily mean that

you've stopped them from seizing. That just now makes

sure that just says that that GTC now I just can't see it, and

so then you definitely want to put this patient on some form of

neuro monitoring to make sure now that yes I've I've

suppressed the shaking part or the tonic clot part of the

seizure, but now they're essentially now just having

non-convulsive status because I've just sedated them enough.

So that patient absolutely needs to have some neuro monitoring,

whether it's conventional EEG, point of care EEG, but that

patient needs to be monitored. And for a lot of times, for us

in these smaller hospitals, that may mean that now I got to

transfer that patient out of the community. And that's again

where some of these point of care devices can help. It can

help us keep these patients in the community because I'm going

to have this device on. Tell you yay or nay if this patient is

still seizing while I'm waiting to talk to neurology, but I may

be able to keep that patient there. I remember one night I

was working in the ED. It was like a late Friday night where

we did not have neurology coverage over the weekend. We

did not have conventional EEG coverage over the weekend, and

we did not have point of care EEG coverage either. This

patient came in from the community for like seized for

status, right for refractory seizures. EMS has started

treatment out in the field. Got him to us in the ED. Still

seizing. We had gone through our progressions with benzos and

more benzos. Now second line agent still seizing. Intubated

the patient. Put him on a propofol drug. But again, I

cannot tell you that this patient is still not having

seizures that I just can't detect because they're so

sedated now, so that patient has to get transferred out. So I

remember calling the transfer center. They got me on the line

with because I'm confirmed. I'm not concerned for non-convulsive

status. Got on the phone with the transfer center. They

connected me with the neurologist at another hospital,

and he and I are talking. And I'm like, man, you know, my

concern is is that yeah, he's intubated, sedated, but that

dude would not stop seizing. Like I'm 30 minutes into this

thing. By the time I'm like, yeah, we just gotta, we just

gotta secure this airway, right? From the time EMS picked him up

to us, it's about 30 minutes. And so I intimated the guy. I'm

like, hey, look, my concern is for non-convulsive status. We

don't have EEG capability here during the day. Sometimes it's

tough. Now you're talking about late at night. Oh no, going into

the weekend, we just don't. And we don't have neurology, right?

And so I think it's much safer for this patient and more

appropriate to get him to where he needs to be with this with

you, a neurologist. And so he was like, I mean, yeah, I mean,

I hear you, but is he still seizing? I was like, no, because

he's intubated and sedated all the hair on a paralyzed him with

rock. He was like, I mean, but if if you don't see him seizing

right now. I mean, that's. I think you fixed it. And I was

like, but isn't that what nonconvulsant seizures are?

That's what I'm concerned about, dude. Like, I'm like, no, he

absolutely cannot stay here. He has to come to you. I, I'm like,

so you saying on this recorded line with the transfer center

that you don't want to transfer this dude to get him

conventional EEG? And he's like, yeah, fine. I guess we'll

transfer him. I'm like, I'm glad we agree, and we transfer the

guy. I'm like, he has to go to a place that is more appropriate

to rule out that he is not still having subclinical seizures. And

this guy, at the very least, has refractory status. He needs to

be with a place where EEG and a neurologist is, and that's not

even open for discussion. Right? He has to get transferred, and

so that's one thing too to consider is that once you make

it to your third line agent, get this patient intubated.

You need to strongly start considering and think about that

next step, which is he needs neuro monitoring. Now that

patient needs more advanced and continuous neuro monitoring. So

we got to get him to a place where that is. If that's

upstairs in your own facility, great. If not, then you need to

be getting on the horn at the transfer center. Just got to try

to get them moved on out of there.

Well, actually, I'm really glad you brought that up because my

next question, in sort of the deployed military settings and

austere environments that you might be having where you don't

have EEG, would your treatment threshold be different in this

prolonged field care combat situation?

Yeah, great question. Right, so I always try to go back to

guidelines, right? And so the guidelines per AHA says they

recommend against like prophylaxing these folks. Like,

well, what if they're seizing? Well, let's give them some

benzos. Well, let's give them some kepra. Let's that's the

guidelines say to not do that, right? Because what we find is

that quite often when we just like prophylax a lot of these

folks, we end up over treating, and some of these patients now

may have to get intubated because we overtreated and

suppress that respiratory drive. Now this patient has to go to

ICU. Now ICU beds as a premium across the country. Now that

patient is going to eat up an ICU bed, which if you could have

just put a monitor on them and see that they're not seizing,

then that could have saved that intubation, saved that

overmedication, saved that ICU bed, but that those guidelines

quite often may not apply to us in a prolonged field care state

because I don't have access to neuro monitoring in a far

forward location, right? And so that becomes a problem. And so,

and that that was always and still to this day is one of the

dilemmas that I always would come up with when transporting a

lot of these patients, whether it be on a Hilo with like dust

off, or when we had tack it, or if it was like Sea Cat, or any

other mode of movement that we do downrange, that was always my

concern, right? And some of these patients that have these

like pretty gnarly and pretty severe TBIs, you know, and we

move these folks pretty rapidly, right, throughout the system to

get them like when it comes of like in route care to get them

to that next level. I mean, if you go back and look at Vietnam,

it would take like weeks to move a lot of these patients. If you

looked at the height of like Afghanistan, OIR and stuff, we

would have these patients back in the states within like four

days. But the question is, what is their brain doing throughout

that movement, and is it safe to move a lot of these patients?

And quite often, we don't really know. Sometimes, right? Because,

and in terms of seizures, I can't tell you if this patient

is seizing because until you get them to like a place like maybe

Lawnstu, right, alarm C, where there probably is some degree of

EEGs, we don't have that further forward downrange, and so that

question to this day has not been answered. And so though I

said let's go back to the guidelines, that those

guidelines ain't tested in the dirt, third like 1000s of miles

away from here, right? When people are being shot at

downrange, right? So we just don't know. There's no clear-cut

answer to that, and so that's why, like, very like if you look

at the Brain Trauma Foundation and with bad TBIs, quite often,

especially if those patients have bleeds, right? Traumatic

brain injuries, traumatic subarachnoids, those patients

will get prophylaxed. Whether that's prophylaxis, then we're

like 500 kepher BID for seven days. That's usually the

standards what we're doing with most of these folks. But when it

comes down to seizures specifically, we just don't

know. We're giving them the kepra to hopefully prevent them

from seizing, but we don't have a test to say let's see if they

are seizing that far forward. Definitely talking about in the

dirt with prolonged field care. There's absolutely no high power

study saying, "Do we know if these patients are seizing?

Like, dude, I can barely get access in blood products and

things like. There's absolutely no way that I know if they're

seizing, and so the guidelines don't apply to that environment

because we've never tested in that environment, which makes it

really, really tough to know. And even if you're talking about

prophylaxins for a head bleed, again, I don't know if they have

a head bleed that fall forward until they've made it back to a

place to where I can get neuroimaging, right? And

sometimes that's further back. We was in Afghanistan. That was

like Bagram, right? And so. But that takes a while to get them

to that area. So in a prolonged field care area, you just don't

know. And so I it's hard.

I'd be kind of hard pressed to say that I would just

prophylactically like give them like Ativan, where Ativan would

be kind of probably not that far forward because remember Ativan

or Lorazepam has to be refrigerated, and which is why

we don't carry some of the other products with us. So fall

forward, it would be like midazolam, right? Of verse aid

that these patients would probably be getting. But again,

I can't say with certainty that we should be prophylacing those

folks because we just don't. We just don't have the data to say

yay or nay one way or the other. Now, if you see them seizing,

then that's an easy one, right? Those patients I treat, they'll

get medazzle that fall forward, and then maybe I would consider

prophylaxis them with if you had levoteracetam or kepra that fall

forward, one of the soft teams or one of these other folks that

are out there that may have a bigger backset with more

medications and drugs in them, if they have capra, then maybe

treat them. If they've had one seizure, I want to do whatever I

can to prevent them from having a second seizure. And that

patient, yes, but for non-convulsive seizures in

particular, that that's that hasn't been studied that far

forward, and I don't think any of the devices, like the point

of care devices, none of them have been tested that far

forward to say, can I put this on a patient and then fly them

to the next point? Because as you know, they would have to be

tested for airworthiness, and none of them have been tested

for airworthiness, and so that's why I can't sit here and say,

oh, just throw the device on and then move them because that

hasn't been proven to be safe and effective. My thought is

you'll probably be safe, but then you have to get down back

to security and safety and all that other stuff that has not

been tested that far forward. But I think it's coming. I think

it's coming. That'd be a great study, right? That'd be a great

study.

It's a thorny issue. Well, we're actually running a little low on

time, but before we wrap up, do you have any places you

recommend people go for further information on this?

Yeah, so Neurocritical Care Society is a big one, and that's

where like all the information is for most part located, like

seizures and nonconvulsive status. Just like an ACLS

course, they have their version of an ACLS course goes into

details about how to manage seizures, regular seizures like

GTCs and all that, as well as non-convulsive seizures. So I

would kind of refer folks back to that. In terms of traumatic

brain injuries that can cause seizures, that's where the Brain

Trauma Foundation and those folks come in. AHA guidelines

that I referred to earlier. They talk about a lot of like what to

do for seizures and a lot of these folks in an ED setting,

right? So folks that come back into it come to us for history

of ischemic strokes. Those patients are at an increased

risk of having seizures. One other patient demographic I

always like to make sure I mention are those patients that

are having like what we consider functional seizures or

psychogenic non-epileptiform seizures. Back in the day, what

we refer to sometimes as pseudo seizures, you have to remember,

yes, they may be having a pseudo seizure or a non epileptic

forming seizure in front of you, or you may suspect that's what

they're having. But you have to remember, those patients still

about 10 to 20% of those patients, right, still have a

history of actual epilepsy, right. And so I wouldn't just

say, oh, that's just a fake seizure, or that's a pseudo

seizure, or that's not a real seizure, whatever you want to

call it. I wouldn't say that, right? Until again, you root out

that that is absolutely not a seizure. It is really, really

hard in some of those patients to say if they're having a true

seizure or this is like psychiatric related. It is

really hard, even for neurologists sometimes without

the data, without some form of an EEG, and some of these point

of care devices can help safely rule that out, right? And so, if

you have that device or one of those devices, I would recommend

putting that on, making sure they're absolutely not seizing,

and then kind of go from there. But again, those patients with

with that we consider to have like psychiatric psychogenic

seizures, that patient still there. There's still a

significant risk of them actually having seizures. And so

again, it has to be on your differential.

Nice. We'll put those resources in the bottom of the show notes.

One other great resource that we really recommend is

ncse-edu.com. It's a website that has multiple lectures on

seizure disorder and some very specific content on

non-convulsive status epilepticus. So I think that's

all the time we have. Thank you so much for coming on,

sir. Thanks for having me, man. It's a true too privilege. Thank

you much. Appreciate you.

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