1. Overlapping Brain States Daniel Erichsen, MD 08/04/2011

2. State(s) of the brain State(s) of the brain Awake Awake Non REM Sleep Non REM Sleep REM sleep REM sleep

3. How do you know? How do you know? Awake Awake Responsive Responsive Talk Talk Hear/Feel/See/Smell Hear/Feel/See/Smell Purposeful movements Purposeful movements Walking Walking Complex movements Complex movements Eating Eating Eyes open Eyes open

4. How do you know? How do you know? Asleep (Non REM sleep) Asleep (Non REM sleep) Unresponsive/Increased sensory threshold. Unresponsive/Increased sensory threshold. Relatively immobile Relatively immobile Absence of purposeful/complex movements Absence of purposeful/complex movements Regular respiration Regular respiration Posture Posture Eyes closed Eyes closed

5. Is it possible to fake sleeping? Is it possible to fake sleeping? Yes Yes

6. How can we objectively tell if someone is sleeping? How can we objectively tell if someone is sleeping? EEG EEG

7. Wake Wake 13 – 30 oscillations per second (Hz) 13 – 30 oscillations per second (Hz) Low amplitude/voltage Low amplitude/voltage = Beta activity = Beta activity

8. Wake, eyes closed/open Wake, eyes closed/open 8 – 13 oscillations per second (Hz) 8 – 13 oscillations per second (Hz) Higher amplitude/voltage Higher amplitude/voltage = Alpha activity = Alpha activity

9. Stage 2 sleep Stage 2 sleep 4 – 8 oscillations per second (Hz) 4 – 8 oscillations per second (Hz) Sleep spindles, K-complexes Sleep spindles, K-complexes Medium amplitude/voltage Medium amplitude/voltage = Theta activity = Theta activity

10. Stage 3 sleep (Slow wave sleep/Delta sleep) Stage 3 sleep (Slow wave sleep/Delta sleep) <4 oscillations per second (Hz) <4 oscillations per second (Hz) High amplitude (>75 mV) High amplitude (>75 mV) = Delta activity = Delta activity

11. State(s) of the brain State(s) of the brain Awake Awake Non REM Sleep Non REM Sleep REM sleep REM sleep

12. Rapid eye movements Rapid eye movements Paralysis / Loss of muscle tone Paralysis / Loss of muscle tone Engorgement of erectile tissue Engorgement of erectile tissue Dreams Dreams

13. REM sleep REM sleep Why paralysis in REM sleep? Why paralysis in REM sleep?

14. Nocturnal penile tumescence testing Nocturnal penile tumescence testing

15. REM sleep REM sleep Beta activity (13-30 Hz) Beta activity (13-30 Hz)

16. Hypnogram Hypnogram

18. “Sorry doc, he has fever 99.8! What to do??”

19. Hypnogram Hypnogram “Sorry doc, he has fever 99.8! What to do??” “We’re out of Enfamilk!”

20. Hypnogram Hypnogram “Sorry doc, he has fever 99.8! What to do??” “We’re out of Enfamil!” “Sorry wrong number…”

21. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamil!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..”

22. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamil!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Pt in 2B lost his IV… Yes the chubby 3 month old..”

23. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamil!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Pt in 2B lost his IV… Yes the chubby 3 month old..” “We’re still out of Enfamilk..”

24. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamil!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Patient 2B lost his IV again… Yes the chubby 3 month old..” “We’re still out of Enfamilk..” “We don’t have a Tylenol order for 5A…”

25. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamilk!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Patient 2B lost his IV again… Yes the chubby 3 month old..” “We’re still out of Enfamilk..” “We don’t have a Tylenol order for 5A…” “Patient 2B lost his IV again..”

26. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamilk!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Patient 2B lost his IV again… Yes the chubby 3 month old..” “We’re still out of Enfamilk..” “We don’t have a Tylenol order for 5A…” “Patient 2B lost his IV again..” “Patient 5A says she can’t sleep..”

27. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamilk!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Patient 2B lost his IV again… Yes the chubby 3 month old..” “We’re still out of Enfamilk..” “We don’t have a Tylenol order for 5A…” “Patient 2B lost his IV again..” “Patient 5A says she can’t sleep..” AAAAAAAAAAHHHHHH !!!!!!

28. Hypnogram Hypnogram “Doc, he has fever 99.8! What to do??” “We’re out of Enfamilk!” “Sorry wrong number…” “We’ve got and admission.. 16 y o with dehydration..” “Patient 2B lost his IV again… Yes the chubby 3 month old..” “We’re still out of Enfamilk..” “We don’t have a Tylenol order for 5A…” “Patient 2B lost his IV again..” “Patient 5A says she can’t sleep..” “Time to sign out!”

29. Hypnogram Hypnogram Ah, finally Morning Report. Zzzzz

30. Can a person be asleep and awake at the same time? Can a person be asleep and awake at the same time?