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Abenza Abildúa MJ, Olmedo Menchen T, Pérez Villena A, Ruhland Paulete S, José Navacerrad F, Barrero, de Ojeda Ruíz de Luna J, Algarra Lucas C, Cordero Martín G, Martínez Ubierna S, Jimeno Montero C, Navarro López IJ, Suárez Gisbert E, Gómez de la Riva Á, Pérez López C, Herreros Fernández ML. Assessment of the diagnostic utility of the electroencephalogram in pediatric emergencies. Neurologia 2024:S2173-5808(24)00069-5. [PMID: 39127155 DOI: 10.1016/j.nrleng.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/15/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION We analyze the diagnostic utility of urgent EEG (electroencephalogram) performed in children under 16 years of age in our center. MATERIAL AND METHODS Descriptive, retrospective, observational study of consecutive patients from 0 to 16 years of age, who underwent an urgent EEG for any reason, from January to December 2022. RESULTS Of the 388 patients, 70 were children: 37 (52.85%) women, and 33 (47.14%) men. Average age: 6.27 ± 4.809. Of the 70 patients, 6 (8.57%) had previous epilepsy. Reasons for consultation: 17 febrile seizures, 10 first focal seizures, 10 first TCG seizures, 6 paroxysmal episodes, 6 absences, 3 myoclonus of extremities, 3 syncope, 2 SE, 2 visual alterations, 2 low level of consciousness, 2 cyanosis, 2 suspected meningitis or encephalitis, 1 choking, 1 atypical headache, 1 chorea, 1 presyncope, 1 language delay. Of the 70 patients, 47 had a normal EEG (67.14%). Of the 47 patients with a normal EEG, 10 were diagnosed with epilepsy, and 3 of them began receiving antiepileptic treatment upon discharge. None of the patients with suspected syncope or paroxysmal disorder (17 patients, 24.28%) had EEG abnormalities. Of the 17 patients with atypical febrile seizures, 3 had EEG abnormalities. CONCLUSIONS A third of the EEG records performed in the Emergency Department showed alterations, probably due to the time taken. Almost half of the patients with suspected epilepsy or EE showed EEG abnormalities, which confirmed the diagnosis in these cases and encouraged the clinician to start drug treatment. No case with a high suspicion of epilepsy was dismissed due to the normality of the EEG recording in our series. No patient diagnosed with syncope or paroxysmal disorder had EEG abnormalities. Nearly a quarter of patients with atypical febrile seizures showed EEG abnormalities. We barely register cases of status epilepticus, probably due to the degree of complexity of our center.
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Affiliation(s)
- M J Abenza Abildúa
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Fundación para la Investigación e Innovación Biomédica del Hospital Universitario Infanta Sofía y Hospital Universitario del Henares, Madrid, Spain.
| | - T Olmedo Menchen
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - A Pérez Villena
- Servicio de Pediatría, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - S Ruhland Paulete
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - F José Navacerrad
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Barrero
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - J de Ojeda Ruíz de Luna
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - C Algarra Lucas
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - G Cordero Martín
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - S Martínez Ubierna
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - C Jimeno Montero
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - I J Navarro López
- Servicio de Pediatría, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - E Suárez Gisbert
- Servicio de Psiquiatría, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Á Gómez de la Riva
- Servicio de Neurocirugía, Hospital La Paz-Cantoblanco-Carlos III, Madrid, Spain
| | - C Pérez López
- Servicio de Neurocirugía, Hospital La Paz-Cantoblanco-Carlos III, Madrid, Spain
| | - M L Herreros Fernández
- Sección de Neurología, Centro de Medicina del Sueño, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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Morgan LA, Sprigg BN, Barry D, Hrachovec JB, Novotny EJ, Akiyama LF, Allar N, Matlock JK, Dervan LA. Reducing Time to Electroencephalography in Pediatric Convulsive Status Epilepticus: A Quality Improvement Initiative. Pediatr Neurol 2024; 152:169-176. [PMID: 38295718 DOI: 10.1016/j.pediatrneurol.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Pediatric convulsive status epilepticus (CSE) is a neurological emergency utilizing electroencephalography (EEG) to guide therapeutic interventions. Guidelines recommend EEG initiation within one hour of seizure onset, but logistic and structural barriers often lead to significant delays. We aimed to reduce the time to EEG in pediatric CSE. METHODS From 2017 to 2022, we implemented process improvements, including EEG order sets with priority-based timing guidance, technologist workflow changes, a satisfaction survey, and feedback from key stakeholder groups, over five plan-do-study-act (PDSA) cycles. Seizure start time, time of EEG order, and time to EEG initiation were extracted. Time to interpretable EEG was determined from manual review of the EEG tracing. RESULTS Time from EEG order to interpretable EEG decreased by nearly 50%, from a median of 90 minutes to 48 minutes. There were clinically and statistically significant improvements in time from EEG order to EEG initiation, time from EEG order to interpretable EEG, and EEG start to interpretable EEG. Ongoing provider education and guidance enabled improvements, whereas a new electronic health care record negatively impacted electronic ordering. EEG technologists reported that they understood the importance of emergent EEG for clinical care and did not find that the new workflow caused excessive disruption. CONCLUSIONS Timely access to EEG for pediatric patients with CSE can be improved through clinical processes that use existing devices and that maintain the benefits of full-montage EEG recordings. Similar process improvement efforts may be generalizable to other institutions to increase adherence to guidelines and provide improved care.
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Affiliation(s)
- Lindsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington.
| | - Brittany N Sprigg
- Division of Pediatric Neurology, Department of Neurology, University of California San Diego, San Diego, California
| | - Dwight Barry
- Clinical Analytics, Seattle Children's Hospital, Seattle, Washington
| | - Jennifer B Hrachovec
- Quality and Clinical Effectiveness, Center for Quality and Patient Safety, Seattle Children's Hospital, Seattle, Washington
| | - Edward J Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Lisa F Akiyama
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Nicholas Allar
- Division of Neurodiagnostics, Seattle Children's Hospital, Seattle, Washington
| | - Joshua K Matlock
- Clinical Analytics, Seattle Children's Hospital, Seattle, Washington
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Green A, Wegman ME, Ney JP. Economic review of point-of-care EEG. J Med Econ 2024; 27:51-61. [PMID: 38014443 DOI: 10.1080/13696998.2023.2288422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/23/2023] [Indexed: 11/29/2023]
Abstract
Aims: Point-of-care electroencephalogram (POC-EEG) is an acute care bedside screening tool for the identification of nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE). The objective of this narrative review is to describe the economic themes related to POC-EEG in the United States (US).Materials and methods: We examined peer-reviewed, published manuscripts on the economic findings of POC-EEG for bedside use in US hospitals, which included those found through targeted searches on PubMed and Google Scholar. Conference abstracts, gray literature offerings, frank advertisements, white papers, and studies conducted outside the US were excluded.Results: Twelve manuscripts were identified and reviewed; results were then grouped into four categories of economic evidence. First, POC-EEG usage was associated with clinical management amendments and antiseizure medication reductions. Second, POC-EEG was correlated with fewer unnecessary transfers to other facilities for monitoring and reduced hospital length of stay (LOS). Third, when identifying NCS or NCSE onsite, POC-EEG was associated with greater reimbursement in Medical Severity-Diagnosis Related Group coding. Fourth, POC-EEG may lower labor costs via decreasing after-hours requests to EEG technologists for conventional EEG (convEEG).Limitations: We conducted a narrative review, not a systematic review. The studies were observational and utilized one rapid circumferential headband system, which limited generalizability of the findings and indicated publication bias. Some sample sizes were small and hospital characteristics may not represent all US hospitals. POC-EEG studies in pediatric populations were also lacking. Ultimately, further research is justified.Conclusions: POC-EEG is a rapid screening tool for NCS and NCSE in critical care and emergency medicine with potential financial benefits through refining clinical management, reducing unnecessary patient transfers and hospital LOS, improving reimbursement, and mitigating burdens on healthcare staff and hospitals. Since POC-EEG has limitations (i.e. no video component and reduced montage), the studies asserted that it did not replace convEEG.
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Affiliation(s)
- Adam Green
- Critical Care Medicine, Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, USA
| | - M Elizabeth Wegman
- Medical Communications, Costello Medical Consulting, Inc, Boston, MA, USA
| | - John P Ney
- Department of Neurology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
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Simma L, Romano F, Schmidt S, Ramantani G, Bölsterli BK. Integrating Neuromonitoring in Pediatric Emergency Medicine: Exploring Two Options for Point-of-Care Electroencephalogram (pocEEG) via Patient Monitors-A Technical Note. J Pers Med 2023; 13:1411. [PMID: 37763178 PMCID: PMC10532774 DOI: 10.3390/jpm13091411] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/08/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Central nervous system (CNS) disorders are among the most frequent presentations in critically ill children. Status epilepticus (SE) is a frequent scenario in the resuscitation bay. In patients with altered mental status, non-convulsive SE (NCSE) is often underrecognized and critically impacts the neurological outcome and duration of hospitalization. An electroencephalogram (EEG) is required to diagnose NCSE. However, standard EEG recordings are time- and staff-intensive, and their availability is limited, especially outside regular working hours. We aimed to improve patient care by developing a simplified EEG recording method, using a reduced lead montage (point-of-care EEG-pocEEG), that is suitable for use in pediatric emergency departments. The objective was to devise a cost-effective unit with low space requirements that fitted the existing technical infrastructure. We present two technical options for clinical pocEEG acquisition using patient monitors (GE Carescape, Philips IntelliVue) that enable data collection for educational and research purposes. A simplified, rapid response EEG like the pocEEG enables neuromonitoring of patients with CNS disorders in pediatric emergency settings, facilitating timely diagnosis and treatment initiation when standard EEG is not readily available.
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Affiliation(s)
- Leopold Simma
- Emergency Department, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
| | - Fabrizio Romano
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Steffen Schmidt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Georgia Ramantani
- Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- Department of Neuropediatrics, University Children’s Hospital, University of Zurich, 8032 Zurich, Switzerland
| | - Bigna K. Bölsterli
- Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- Child Development Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zurich, Switzerland
- Department of Pediatric Neurology, Children’s Hospital of Eastern Switzerland, 9000 Sankt Gallen, Switzerland
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Ospina Jimenez C, Sivaswamy L, Castellucci G, Taskin B, Farooqi A, Kannikeswaran N. Yield of Neurodiagnostic Testing in Children Presenting to a Pediatric Emergency Department With Altered Mental Status. Pediatr Neurol 2023; 146:8-15. [PMID: 37379589 DOI: 10.1016/j.pediatrneurol.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/07/2023] [Accepted: 05/28/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Emergency department (ED) visits for altered mental status (AMS) in children are common. Neuroimaging is often performed to ascertain etiology, but its utility has not been well studied. Our objective is to describe the yield of neuroimaging studies in children who present to an ED with AMS. METHODS We performed a retrospective chart review of children 0-18 years of age, presenting to our PED between 2018 and 2021 with AMS. We abstracted patient demographics, physical examination, neuroimaging and EEG results, and final diagnosis. Neuroimaging and EEG studies were classified as normal or abnormal. Abnormal studies were categorized as clinically important and contributory: abnormalities that were clinically important and contributed to the etiology, clinically important but noncontributory: abnormalities that were clinically significant but did not explain the etiology, and incidental: abnormalities that were not clinically significant. RESULTS We analyzed 371 patients. The most common etiology of AMS was toxicologic (188, 51%) with neurologic causes (n = 50, 13.5%) accounting for a minority. Neuroimaging was performed in one-half (169, 45.5%) and abnormalities were noted in 44 (26%) studies. Abnormalities were clinically important and contributed to the etiologic diagnosis of AMS in 15/169 (8.9%), clinically important and noncontributory in 18/169 (10.7%), and incidental in 11/169 (6.5%). EEG was performed in 65 patients (17.5%), of which 17 (26%) were abnormal with only one being clinically important and contributory. CONCLUSIONS Though neuroimaging was performed in approximately one half of the cohort, it was contributory in a minority. Similarly, diagnostic utility of EEG in children with AMS was low.
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Affiliation(s)
| | - Lalitha Sivaswamy
- Professor of Pediatrics and Neurology, Division of Neurology, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
| | - Giovanni Castellucci
- Pediatric Neurology Resident, Children's Hospital of Michigan, Detroit, Michigan
| | - Birce Taskin
- Pediatric Neurology Resident, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- Assistant Professor Biostatistics, Clinical Research Institute CMU College of Medicine, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Professor of Pediatrics & Emergency Medicine, Division of Emergency Medicine, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
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Barton DJ, Coppler PJ, Talia NN, Charalambides A, Stancil B, Puccio AM, Okonkwo DO, Callaway CW, Guyette FX, Elmer J. Prehospital Electroencephalography to Detect Traumatic Brain Injury during Helicopter Transport: A Pilot Observational Cohort Study. PREHOSP EMERG CARE 2023; 28:405-412. [PMID: 36857200 PMCID: PMC10497709 DOI: 10.1080/10903127.2023.2185333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE Early recognition of traumatic brain injury (TBI) is important to facilitate time-sensitive care. Electroencephalography (EEG) can identify TBI, but feasibility of EEG has not been evaluated in prehospital settings. We tested the feasibility of obtaining single-channel EEG during air medical transport after trauma. We measured association between quantitative EEG features, early blood biomarkers, and abnormalities on head computerized tomography (CT). METHODS We performed a pilot prospective, observational study enrolling consecutive patients transported by critical care air ambulance from the scene of trauma to a Level I trauma center. During transport, prehospital clinicians placed a sensor on the patient's forehead to record EEG. We reviewed EEG waveforms and selected 90 seconds of recording for quantitative analysis. EEG data processing included fast Fourier transform to summarize component frequency power in the delta (0-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) ranges. We collected blood samples on day 1 and day 3 post-injury and measured plasma levels of two brain injury biomarkers (ubiquitin C-terminal hydrolase L1 [UCH-L1] and glial fibrillary acidic protein [GFAP]). We compared predictors between individuals with and without CT-positive TBI findings. RESULTS Forty subjects were enrolled, with EEG recordings successfully obtained in 34 (85%). Reasons for failure included uncharged battery (n = 5) and user error (n = 1). Data were lost in three cases. Of 31 subjects with data, interpretable EEG signal was recorded in 26 (84%). Mean age was 48 (SD 16) years, 79% were male, and 50% suffered motor vehicle crashes. Eight subjects (24%) had CT-positive TBI. Subjects with and without CT-positive TBI had similar median delta power, alpha power, and theta power. UCH-L1 and GFAP plasma levels did not differ across groups. Delta power inversely correlated with UCH-L1 day 1 plasma concentration (r = -0.60, p = 0.03). CONCLUSIONS Prehospital EEG acquisition is feasible during air transport after trauma.
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Affiliation(s)
- David J. Barton
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nadine N. Talia
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
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