Novel Emergency Medicine Curriculum Utilizing Self-Directed Learning and the Flipped Classroom Method: Neurologic Emergencies Small Group Module

Audience: This is a group discussion, case-based curriculum to cover emergency medicine neurology core content. It was created and implemented at The Ohio State University Emergency Medicine Residency program and was designed to educate our emergency medicine (EM) residents, PGY-1 to PGY-3, as well as medical students and attending physicians. Length of Curriculum: The neurologic emergencies module consists of eight 45-60-minute small group sessions for a total of six to eight hours of content. This curriculum block is part of an overall 18-month emergency medicine residency curriculum. Introduction: In 2015, approximately 7 million emergency department visits were related to diseases of the nervous system. Headache alone represented 2.8% of all emergency department visits, making it the fifth most common chief complaint.1 Residents must be proficient in the differential diagnosis and management of the wide variety of neurological emergencies. To address this specific curricular need, we developed a flipped classroom case-based small group discussion series for emergency medicine learners that emphasizes self-directed learning activities, followed by facilitated small group discussions pertaining to the topic reviewed. The active learning fostered by this curriculum increases faculty and learner engagement and interaction time typically absent in traditional lecture-based formats.2-4 The application of knowledge through case studies, personal interaction with content experts, and integrated questions are effective learning strategies for emergency medicine residents.4-6 Educational Goals: We aim to teach the presentation and management of neurologic emergencies through the creation of a flipped classroom design. This unique, innovative curriculum utilizes resources chosen by


Objectives:
After completing the neurologic emergencies module, resident learners will exhibit mastery within this content area and will critically discuss the pathophysiology, diagnosis, and treatment of various pediatric and adult neurologic emergencies including: 1. Acute Headache a. Discuss the differential diagnosis for patients presenting to the ED with acute headache. b. Review the causes of primary and secondary headaches. c. Discuss the diagnostic workup and indications for imaging in patients with acute headache.

Brief introduction:
In 2015, approximately 7 million emergency department visits were related to diseases of the nervous system. Headache alone represented 2.8% of all emergency department visits, making it the fifth most common chief complaint. 1 Neurologic conditions such as ischemic stroke and intracerebral hemorrhage are major causes of severe long-term disability and death. 8 In these, as well as other emergent neurologic conditions, the amount of injury to the central nervous system is critically dependent on the duration of the underlying pathology. Rapid recognition and treatment are vitally important in limiting morbidity and mortality associated with these conditions. 9 Therefore, emergency medicine residents must be proficient in the differential diagnosis and management of a wide variety of neurological emergencies. To address this specific curricular need, we developed a flipped classroom, case-based small group discussion series for emergency medicine learners.
The flipped classroom learning approach is becoming more commonly recognized as a preferred curricular model for mature learners, specifically those in medical education. This particular model is a natural fit for the hands-on, experiential emergency medicine learner. 4 The active learning fostered by this curriculum increases faculty and learner engagement and interaction time, which is typically absent in traditional lecturebased formats. 5,10 Education literature shows that resident learners prefer learning activities that involve small group discussion, are case-or skill-based, and emphasize the application of newly obtained knowledge. 3,4 This educational model also provides a clear channel for the incorporation of evidence-based medicine and increases opportunities for educator-learner conversations. A successful flipped classroom curriculum fosters learner accountability and provides robust opportunities for formal assessment in various emergency medicine milestones. 4, 10, 11 Accordingly, we have transitioned our traditional lecture-based didactics to a flipped classroom curriculum at The Ohio State University Emergency Medicine Residency. This neurologic emergencies curriculum is one of several topics in our overall didactic curriculum. [12][13][14][15][16][17][18][19][20] Problem identification, general and targeted needs assessment: Neurologic emergencies are identified as an important aspect of an emergency medicine curriculum as outlined in the ABEM model EM curriculum. 7 This topic makes up a significant portion of the content that will appear on the emergency medicine intraining exam. Consequently, we decided that neurologic emergencies warranted a dedicated content block within our curriculum.
Prior to the implementation of this curriculum, education faculty leadership identified the topic areas to cover based on the neurologic emergencies identified in the ABEM model EM curriculum. 7 . The topics covered represent the disease processes considered most critical in the EM model of practice that are not covered elsewhere in our didactic series. These topics were then assigned to core faculty educators who developed the small group modules. Education faculty leadership edited the modules for content and consistency. Dissemination of the modules and associated learning resources was accomplished by posting on a digital learning management system for faculty and resident review prior to the sessions.

Evaluation and Feedback:
This innovative curriculum was literature-based and specifically designed to maximize active learning using the flipped classroom learning model. We overcame initial challenges and skepticism from both educators and learners to execute a successful, novel curricular model. Both resident learners and faculty educators have provided an overwhelming amount of positive feedback. Additionally, residents were surveyed on their perceived quality of instruction of the various program components each year. In the year prior to implementation of this curricular innovation, only 52% of residents completing the survey (n=28) rated the quality of small group discussion as good or excellent, whereas 68% of respondents (n=19) rated the quality as good or excellent after the conclusion of the first year. Learners and educators were enthusiastic about the conference structure and expressed a preference for it rather than the previous, lecture-based didactics. More recently during the second 18-month cycle of the flipped classroom curriculum, 63% of residents responding to the survey (n=38) reported that the small group discussions were good or excellent, compared to only 24% of residents that felt that our grand rounds sessions during the same time were good or excellent. This curriculum has been delivered to two cohorts of learners, having delivered the content twice in three years with about 50 residents per cycle. On the most recent iteration, residents evaluated the teaching methods as effective, with an average rating of more than 4.3 out of 5 (4 being agree, 5 being strongly agree). The curriculum is critically evaluated and updated by education faculty members in order to ensure educational material remains current and consistent with the emergency medicine core content. Future research will be needed to investigate the potential effects of this curriculum on in-training exam (ITE) scores and clinical performance.
Significant faculty time was required to develop and update these small group modules. This time commitment may limit the wide-spread adoption of the flipped classroom model for residency education. But we hope that this content will help jump start a similar implementation at other emergency medicine residency programs. Future work could focus readings and materials on different levels of learners, so that it is more specifically tailored to both the junior and senior resident.  Leung Leung Leung

Case Studies
Case 1: A 28-year-old female with history of morbid obesity presents with daily headaches that started two months ago and have become constant for the past week. She has never had this type of headache before. The pain is diffuse and bilateral and associated with mild nausea and occasional blurred vision. She notices improvement with ibuprofen but the headache never goes away completely. She feels that the headache worsens when lying down.

Question Prompts:
1. What is the differential diagnosis for acute headache? a. The differential diagnosis includes both primary and secondary types of headache. i. Primary headaches include migraine (with or without aura), tension headache, and the trigeminal autonomic cephalgias such as cluster headache and paroxysmal hemicrania. ii. Secondary headaches arise from numerous different etiologies, ranging from benign causes to potentially life-threatening causes. a. In the acute setting, LP provides symptom relief in most patients; however, closing pressure should be reduced to no more than 50% of opening pressure to avoid low pressure headache and the theoretical risk of tonsillar herniation. b. Long-term symptom control may be attained through weight reduction, medications (acetazolamide, furosemide, topiramate), optic nerve fenestration, CSF diversion, or dural sinus stenting. Acetazolamide and topiramate both have significant side effects and require dose titration. Therefore, it is reasonable to defer starting these medications until the patient receives outpatient follow-up.
Case 2: An 18-year-old female presents with episodic left-sided, throbbing headaches that occur three to four times per month. The headaches started five years ago, but seem to have increased in severity. They are associated with nausea and she sees waves of light about 30 minutes before the pain begins. Light and noise make the headache worse. Ibuprofen and rest usually provide relief. Her mom and sister have a history of similar headaches. i. regular sleeping/eating habits ii. stress reduction iii. avoidance of triggers iv. medications (triptans, amitryptyline, depakote, topiramate, and propranolol). c. Abortive measures used in the ED usually consists of a migraine "cocktail" i. Neuroleptic agents -prochlorperazine, haloperidol, metoclopramide, promethazine, chlorpromazine. ii. Nonsteroidal anti-inflammatory drugs (NSAIDs) -15mg intravenous (IV) ketorolac, with lower doses many times having similar efficacy. NSAIDs alone without neuroleptic agents have a relatively low rate of success in ED patients with severe migraine symptoms. d. Other adjuncts (second line) -magnesium, depakote, and IV fluids. e. Sphenopalatine ganglion blocks are safe and easy to perform in the ED and may provide significant symptom relief in the setting of acute headache. 4 f. Dihydroergotamine (DHE) is another medication that may be considered, but is generally not used in the ED setting due to its potential side effect profile. Although extremely rare, DHE can potentially cause vasospasm leading to cerebral, cardiac or peripheral ischemia and is therefore contraindicated in patients with a history of cardiovascular disease or poorly controlled hypertension. However, DHE is well tolerated by most patients, with the most common adverse effects being nausea, flushing, dizziness, and rebound headache. g. Diphenhydramine is commonly co-administered to prevent extrapyramidal side effects of the neuroleptic agents such as akathisia and dystonic reactions. However, there is currently no evidence that diphenhydramine decreases this rate of akathisia. 5 h. Corticosteroids should be offered for prevention of headache recurrence in patients with a classic migraine history/status migrainosus. However, caution should be taken to avoid Leung

Case Studies
Case 1: A 24-year-old female is brought to the emergency department (ED) by ambulance for severe headache. She has a history of migraine headaches but states that this is more intense than any prior headache. When taking her history, you discover that her typical headache is unilateral and associated with an aura and that this headache was more sudden in onset and more diffusely painful. She was evaluated by a midlevel provider and medicated with ketorolac, prochlorperazine, and diphenhydramine intravenously (IV) while her case was being staffed. She tells you that these medications nearly completely resolved her headache.
Physical Exam: The patient appears uncomfortable but is alert and oriented. Neurologic exam is normal. There is no meningismus or rash. Remaining physical exam is normal.
Question Prompts: 1. Describe the epidemiology, risk factors, and pathophysiology of this condition. a. The incidence of SAH varies widely in different regions of the world, which may be related to genetic differences between populations. Estimated incidence in the US is approximately 30,000 per year. In general, the incidence and prevalence of SAH increases with rising age. Women are more frequently affected than men. b. Non-traumatic SAH is most commonly caused by the rupture of a cerebral aneurysm (75%) or brain arteriovenous malformation (AVM, 10%). Accordingly, personal or family history of cerebral aneurysm (or associated disorders such as polycystic kidney disease or certain connective tissue disorders) confers increased risk of SAH. c. Hypertension, tobacco and alcohol abuse, and use of sympathomimetic drugs also increase risk of SAH. 2. Should diagnostic evaluation of headache be pursued in this case presentation? Leung  a. Diagnostic evaluation should be pursued because this patient exhibits two symptoms which may be considered potential "red flags" for serious secondary headache. She reports that this is the worst headache of life, and that this is a significant change in character from her typical migraine. These symptoms are concerning for SAH. b. Others features suggestive of SAH include maximal headache within a few minutes of onset, onset with exertion, onset associated with syncope, neck pain and history of a "sentinel" headache in the days to weeks prior. c. Response to treatment is not indicative of benign headache as approximately one third of patients with SAH have resolution of headache with medication. 3. What are the potential strategies for diagnostic evaluation of SAH?

DIDACTICS AND HANDS-ON CURRICULUM
a. The sensitivity of non-contrast head computed tomography (CT) for detecting SAH approaches 100% when read by an experienced neuroradiologist within the first six hours after symptom onset. However, sensitivity falls to 50% by 1 week. Further testing should be done beyond non-contrast CT such as lumbar puncture or CT angiogram if the headache symptoms started more than 6 hours prior. 3 b. Therefore, in other cases with clinical suspicion of SAH, additional testing to rule out SAH must be performed. Either lumbar puncture (LP) or CT angiography (CTA) may be performed as the next step in diagnostic workup for SAH. The combination of non-contrast head CT + LP has 100% sensitivity for detecting SAH, but specificity of only about 65%. 4 Because the majority of SAH is caused by cerebral aneurysms, CTA can be useful to rule out presence of bleeding aneurysm as well as guide therapy for aneurysm repair. CTA is 98% sensitive and 100% specific at detecting aneurysms greater than 3mm in the setting of SAH. The risk of SAH with negative CT + CTA is estimated to be less than 1%. 5 However, the discovery of incidental non-ruptured aneurysms may lead to potentially unnecessary downstream testing; therefore, CTA should be reserved only for select patients with a reasonable suspicion of SAH. 4. How do you interpret spinal fluid analysis in the context of potential SAH? a. Cerebrospinal fluids (CSF) analysis is typically accomplished by performing cell counts on four sequentially collected tubes of CSF. The likelihood of SAH is inferred from the number or percent change in RBCs between the first tube of CSF and the last tube of CSF collected. b. Unfortunately, it is difficult to determine if CSF RBCs are due to true SAH or incidental to perforation of epidural vessels during lumbar puncture. Therefore, algorithms using CSF RBC count tend to overestimate the likelihood of SAH. One small study showed that RBCs <100 in the final tube were not associated with SAH, whereas RBCs >10,000 increased odds of SAH by 6-fold. In addition, a percent change of less than 63% between the first tube and the final tube is more likely to represent true SAH. 6  xanthochromia which is not considered to be as sensitive as spectrophotometry. Therefore, detection of xanthochromia may not be a reliable indicator of SAH in all settings.
Case 2: A 49-year-old male with no known past medical history presents to the ED via ambulance complaining of a severe headache while sitting at his desk at work about one hour ago. It started suddenly and reached maximal intensity within a few seconds. He said it felt like something hit him out of nowhere. After the pain started, he had a near-syncopal episode that prompted colleagues to call emergency medical services. On exam, patient is alert and oriented, well developed, and well nourished. He appears slightly uncomfortable.
Physical Exam: His head is atraumatic, cervical spine is nontender, and heart and lungs are normal. There are no focal deficits noted on neurologic exam.
Question Prompts: 1. How would you approach the management of this patient? Describe potential interventions that may benefit this patient. a. The goal of management is to prevent re-bleeding which is associated with increased morbidity and mortality. b. Surgical clipping or endovascular coiling of the ruptured aneurysm is the definitive therapy for SAH and should be performed as soon as possible to reduce risk of re-bleeding. c. Tight blood pressure control is recommended to reduce the risk of hypertension-related rebleeding until the patient has received definitive therapy. There is a paucity of data to support specific blood pressure parameters; however, a goal of systolic blood pressure (SBP) less than 140-160mm hg is usually recommended. Hypotension should be avoided because the resulting decrease in cerebral perfusion pressures may lead to cerebral ischemia and worsen outcomes. Mental status can be used as a marker for adequate cerebral perfusion pressure, and thus in awake/alert patients aggressive blood pressure goal of less than 140mm hg can be obtained. In comatose or intubated patients, be cautious in aggressively lowering blood pressure because it is unclear if they are maintaining adequate cerebral perfusion pressure, and such decisions should be made in consultation with a neurosurgeon. d. Potential anti-hypertensive agents include labetalol, nicardipine, or enalapril. 2. What complications may be expected as a result of this condition? What therapies should be initiated to prevent and treat these complications? a. Early complications of SAH include hydrocephalus and seizure, while the major late complication is delayed cerebral ischemia from vasospasm. b. Acute hydrocephalus occurs in a substantial proportion of patients with SAH. Management consists of CSF diversion via external ventricular drain or lumbar drain. Aggressive blood pressure management should be delayed for these patients until the hydrocephalus is treated; however, there are no clear guidelines for blood pressure goals in this patient population. c. Up to 25% of patients with SAH experience seizures. Risk factors for developing seizures in the setting of SAH include middle cerebral artery (MCA) aneurysm, associated intracerebral hematoma, re-bleeding, infarction, and poorly controlled hypertension. Antiepileptics should be initiated for patients with active seizure and may be considered in patients with known risk factors. d. Delayed cerebral ischemia (DCI) associated with cerebral artery vasospasm is a major cause of death and disability in patients with SAH. Oral nimodipine 60mg every 4 hours for 21 days has been shown to improve neurologic outcomes and should be administered to all patients with SAH within 96 hours of symptom onset. Maintenance of euvolemia is recommended to prevent DCI, and hemodynamic augmentation (via hypervolemia and hypertensive agents) is recommended to treat DCI.

Case Studies
Case 1: A 56-year-old female with a past medical history of hypertension and diabetes presents to the emergency department (ED) via emergency medical services (EMS) as a stroke alert with complaints of acute right-sided weakness while at work approximately 45 minutes ago. Emergency medical services reports that the patient was alert and oriented with clear speech on their arrival, but that she has decompensated when pulling into the ambulance bay. On arrival in the ED, the patient is actively vomiting.
Physical exam: A quick bedside assessment reveals that she has moderate confusion, garbled speech and R hemiparesis.
You direct EMS to bypass the computed tomography (CT) scanner and place the patient in a critical care bay.

Question Prompts:
1. What is the suspected diagnosis? How does the clinical presentation differ from ischemic stroke? a. The suspected diagnosis is ICH. Symptoms of ICH overlap with those of ischemic stroke and often include focal neurologic symptoms. However, symptoms of increased intracranial pressure (ICP) such as headache, nausea, vomiting, seizures, and decreased level of consciousness often dominate the clinical picture in ICH. The presentation also differs from that of ischemic stroke in that symptoms typically progress over minutes to hours. b. Additionally, as in our case, brain herniation is much more common with ICH and often develops within 24 hours, sometimes prior to ED arrival. Herniation can be identified by an acute change in mental status, or an abrupt onset of Cushing's reflex (hypertension, bradycardia and irregular breathing). On the other hand, in ischemic stroke, herniation is less common and often due to large territory infarcts, and typically develops with a delayed DIDACTICS AND HANDS-ON CURRICULUM Leung  onset (greater than 24 hours). In ischemic stroke, intracranial pressure increases more gradually as a result of developing brain edema. 2. Why was the patient diverted from the CT scanner? What special considerations must be taken in the management of airway, breathing and circulation (ABCs)? a. The patient presented with a rapid decline in mental status which carries a high risk of airway compromise due to depressed level of consciousness. Patients with ICH require close monitoring and frequent re-assessment of neurologic status because 20% of patients decline by two or more Glasgow Coma Scale (GCS) points from the time of initial evaluation by EMS to the time of arrival in the ED. An additional 20% show further decline in GCS over the first few hours after arrival. Therefore, you must maintain readiness to intervene on ICH patients for airway protection. b. Patients with ICH may also have respiratory insufficiency due to neurogenic pulmonary edema or comorbid conditions such as hypertensive heart failure that can produce hypoxemia and worsen stroke symptoms. A quick assessment of oxygenation, respiratory rate and respiratory effort will help determine if the patient may require intubation for primary ventilatory support even if the airway is intact. c. Finally, patients with confirmed ICH must have blood pressure tightly controlled to avoid further neurologic deterioration. Rapidly decreasing systolic blood pressure (SBP) to goal of 140 is safe and improves neurologic outcomes. However, hypotension must be strictly avoided to prevent further decreases in cerebral blood flow to at-risk tissues. 3. Describe the neuroprotective strategy for airway management in the patient with ICH.
a. The goal is to blunt the reflex-mediated rise in ICP associated with laryngoscopy and prevent further neurologic deterioration. As such, it is important to ensure that the patient has adequate sedation and analgesia prior to intubation. Fentanyl (3-5 mcg/kg) and esmolol (1.5-2mg/kg) have been shown to blunt the hemodynamic response to laryngoscopy and may be useful in blunting reflex rise in ICP. However, there is no clear evidence that either of these agents improves outcomes. b. If used, these agents should be administered 3 minutes before induction of anesthesia. Preoxygenation of the patient should also occur during this time. c. Blood pressure control should ideally be initiated before intubation. However, push-dose vasopressors should also be available at the bedside because the agents used for pretreatment may cause transient hypotension. d. The patient should remain upright (head of bed 30 degrees or higher) until conditions have been optimized and all equipment is ready to intubate the patient.
Case 2: A 78-year-old male with a history of hypertension and atrial fibrillation presents to the ED via EMS after family found him lying on the floor confused and unable to stand up. In the ED, the patient is lethargic, opening eyes only to stimulation.
Physical exam: He is confused, but follows simple commands with all four extremities. Leung  Uncontrolled hypertension leads to accelerated atherosclerosis and arteriosclerosis of medium and small penetrating vessels within the deep structures of the brain, while amyloid angiopathy leads to fibrinoid necrosis of intraparenchymal cortical vessels. Both types of angiopathy may predispose to microaneurysm formation and make the vessel wall brittle and vulnerable to shear stress caused by elevated blood pressure. c. The most common secondary cause of ICH is anticoagulation. Other less frequent etiologies include arteriovenous malformation (AVM), cavernous malformation, aneurysm, conversion of an ischemic stroke, tumor, and sinus thrombosis. d. Regardless of etiology, an enlarging hematoma is associated with increased morbidity and mortality. Hematoma expansion leads to local mass effect, intraventricular extension and hydrocephalus (independent predictor of mortality), and eventual herniation. Secondary brain injury may also be due to toxic effects of hemoglobin breakdown and other inflammatory mediators. 2. Discuss the diagnostic workup for ICH. Leung  The diagnostic workup for ICH should include non-contrast head CT and point-of-care glucose to exclude alternate diagnoses. Complete blood count (CBC), metabolic panels and coagulation studies should also be obtained to screen for potential bleeding diatheses and guide medical therapy. b. Computed tomography angiogram may be useful when available to rule out vascular abnormalities and discern a "spot sign," an area of contrast extravasation in the hematoma which may represent the site of initial vessel breakdown. c. The spot sign is associated with greater hematoma expansion and poor outcome; therefore, patients with this sign may need more aggressive medical management, as well as more frequent and earlier repeat scans to ascertain stability. 3. What is the approach to initial management of the patient? a. Hematoma growth is associated with higher blood pressures 2 . Rapidly decreasing SBP to goal of less than 140 mmHg is safe and improves neurologic outcomes compared to conservative control. 3 There is no consensus on best agents to use. Nicardipine or labetalol drips are commonly used, but also consider bolus dosing of labetalol, hydralazine or enalapril. Avoid hypotension because it may lead to reduced cerebral blood flow and worsening symptoms. If patients have refractory hypertension despite treatment, consider better pain control. b. Reversal of endogenous or medication-induced bleeding diatheses is important to limiting hematoma expansion. Patients on anticoagulant therapy should be reversed with the appropriate reversal agent [fresh frozen plasma (FFP) + vitamin K or prothrombin complex concentrate (PCC)] for most oral anticoagulants, protamine sulfate for heparin-based anticoagulants). Replacement of factor or platelets is indicated for patients with known factor deficiencies or platelet disorders. c. Control ICP.

DIDACTICS AND HANDS-ON CURRICULUM
i. Maintain the head of the bed at 30 degrees and ensure adequate pain control and/or sedation. ii. Optimize ventilation to titrate RR to paCO2 of [35][36][37][38] iii. Osmotic agents such as mannitol or hypertonic saline can be used for patients with symptoms of increased ICP. iv. Some patients may benefit from early surgical intervention -early consultation with a neurosurgeon is always indicated. d. Other considerations in the initial management of ICH include antiepileptics (levetiracetam preferred) for treatment of seizures, early neurosurgical consultation because patient may eventually need ventricular drain or decompressive craniotomy, and early admission to a neurocritical care ICU.

Case Studies
Case 1: A 27-year-old male presents by emergency medical services (EMS) after he was reportedly found down with jerking movements. The duration of the event is unknown. He was not shaking and generally unresponsive when the ambulance arrived. He was breathing spontaneously and started moaning as they unloaded him into the emergency department (ED). He was still not following commands and responding to voice.
Past medical history, medications and social history are unknown at this point. ii. Point-of-care glucose. iii. Check for signs of trauma and cervical spine tenderness. iv. Otherwise these patients can be managed with little ED testing. 3. What is your initial management in this patient? What is the disposition? a. Initial management would likely be first-time seizure work-up as described above. Ideally providers could reach out to family/friends to obtain additional history to see if the patient has a previous history of seizures. b. Disposition would be based on diagnostic work-up findings, underlying etiology if found, and return to baseline. 4. What would you include with your discharge instructions for a first-time seizure patient who can be discharged from the ED? a. Instructions not to drive, swim, bathe or participate in other potentially dangerous activities, especially alone, are important. i. States vary in driver licensing requirements regarding episodes of loss of consciousness, including the responsibilities of clinicians to notify state authorities. ii. One suggested resource to see laws in your practice location can be found at the epilepsy foundation website -https://www.epilepsy.com/driving-laws. Leung  viii. Hypoglycemia -common in diabetic patients who take excessive amounts of insulin or oral hypoglycemic agents. Islet cell tumors are much less common, but seizures may be the initial presentation. ix. Hyperglycemia -non-ketotic hyperglycemia most commonly occurs in diabetic older adults and can cause focal motor seizures. x. Hyponatremia -precipitous falls in serum sodium concentrations can trigger generalized tonic-clonic seizures, usually in association with a prodrome of confusion and depressed level of consciousness. xi. Hypocalcaemia -most often occurs in neonates. In adults, hypocalcaemia may occur after thyroid or parathyroid surgery or in association with renal failure, hypoparathyroidism, or pancreatitis. xii. Hypomagnesaemia -magnesium levels below 0.8 mEq/L may result in irritability, agitation, confusion, myoclonus, tetany, and convulsions, and may be accompanied by hypocalcemia. xiii. Uremia -renal failure and uremia are often associated with seizures, particularly myoclonic seizures. Generalized tonic-clonic seizures occur in approximately 10% of patients with chronic renal failure. Seizures may also occur in patients undergoing dialysis as part of the dialysis disequilibrium syndrome. xiv. Hyperthyroidism. xv. Disorders of porphyrin metabolism -acute intermittent porphyria. xvi. Eclampsia -during pregnancy or the early post-partum period. xvii. Withdrawal states -particularly alcohol and benzodiazepine withdrawal, is associated with seizures. xviii. Drug intoxication, poisoning, and overdose -cocaine, amphetamines, phencyclidine (PCP) and other illicit substances. Isoniazid, tricyclic antidepressants, and sodium channel blockers. Leung  Case 2: An 11-month-old female presents by EMS after reported seizure. Parents noted that one hour prior to arrival, her eyes rolled back in her head and she demonstrated jerking movements in both arms and legs. She subsequently developed central cyanosis. The event lasted for approximately three minutes and she returned to being somnolent, but interactive by the time EMS arrived. Parents have noted recent nasal discharge and cough. The child is unvaccinated. Leung

Small Group Evaluation
The moderator demonstrated adequate knowledge of subject.

5) Strongly
Agree 4) Agree 3) Slightly Agree 2) Disagree 1) Strongly Disagree The moderator's facilitation of the conference facilitated my learning.

5) Strongly Agree 4) Agree 3) Slightly Agree 2) Disagree 1) Strongly Disagree
The overall discussion was relevant to the stated topic(s).

Preparation -was faculty well prepared?
Needs Improvement Effective Exemplary

Engaged residents -Encouraged discussion and actively participated, demonstrated enthusiasm?
Needs Improvement Effective Exemplary Strengths: Areas for Improvement: Reviewer Recommendations:

Preparation -was the resident facilitator well prepared?
Needs Improvement Effective Exemplary