Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures

Nonconvulsive Status Epilepticus: A Review for Emergency Clinicians

BACKGROUND

Status epilepticus is associated with significant morbidity and mortality and is divided into convulsive status epilepticus and nonconvulsive status epilepticus (NCSE).

OBJECTIVE

This review provides a focused evaluation of NCSE for emergency clinicians.

DISCUSSION

NCSE is a form of status epilepticus presenting with prolonged seizure activity. This disease is underdiagnosed, as it presents with nonspecific signs and symptoms, most commonly change in mental status without overt convulsive motor activity. Causes include epilepsy, cerebral pathology or injury, any systemic insult such as infection, and drugs or toxins. Mortality is primarily related to the underlying condition. Patients most commonly present with altered mental status, but other signs and symptoms include abnormal ocular movements and automatisms such as lip smacking or subtle motor twitches in the face or extremities. The diagnosis is divided into electrographic and electroclinical, and although electroencephalogram (EEG) is recommended for definitive diagnosis, emergency clinicians should consider this disease in patients with prolonged postictal state after a seizure with no improvement in mental status, altered mental status with acute cerebral pathology (e.g., stroke, hypoxic brain injury), and unexplained altered mental status. Assessment includes laboratory evaluation and neuroimaging with EEG. Management includes treating life-threatening conditions, including compromise of the airway, hypoglycemia, hyponatremia, and hypo- or hyperthermia, followed by rapid cessation of the seizure activity with benzodiazepines and other antiseizure medications.

CONCLUSIONS

An understanding of the presentation and management of NCSE can assist emergency clinicians in the care of these patients.

Pathology testing in non-trauma patients presenting to the emergency department with recurrent seizures

OBJECTIVE

Excessive pathology testing is associated with ED congestion, increased healthcare costs and adverse patient health outcomes. This study aimed to determine the frequency, yield and influence of pathology tests among patients presenting to the ED with atraumatic recurrent seizures.

METHODS

This was a retrospective cohort study conducted at a level 4 adult ED in Australia and included atraumatic patients presenting to ED with recurrent seizures over a 4-year period (2017-2020). The primary outcome was the frequency of pathology tests. Additionally, the proportion of abnormal pathology test results and the association between pathology tests and change in management were assessed.

RESULTS

Of the 398 eligible presentations, 346 (86.9%, 95% confidence interval [CI] 83.3-89.9%) underwent at least one pathology test. In total 18.3% (n = 517) of pathology tests had an abnormal result which led to 15 changes in ED management among 12 presentations. Patients who had an abnormal pathology test result were more likely to undergo a change in antiepileptic drug management (odds ratio 2.08, 95% CI 1.23-3.65; P = 0.008).

CONCLUSION

Most patients presenting to the ED with atraumatic recurrent seizures underwent pathology tests. Abnormalities were frequently detected but were uncommonly associated with change in management. Abnormal pathology test results were associated with changes in antiepileptic drug management although rarely led to acute changes in patient management. This study suggests that pathology tests may be excessively requested in this population.

Prognosis and management of acute symptomatic seizures: a prospective, multicenter, observational study

BACKGROUND

Acute symptomatic epileptic seizures are frequently seen in neurocritical care. To prevent subsequent unprovoked seizures, long-term treatments with antiseizure medications are often initiated although supporting evidence is lacking. This study aimed at prospectively assessing the risk of unprovoked seizure relapse with respect to the use of antiseizure medications. It was hypothesized that after a first acute symptomatic seizure of structural etiology, the cumulative 12-month risk of unprovoked seizure relapse is ≤ 25%.

METHODS

Inclusion criteria were age ≥ 18 and acute symptomatic first-ever epileptic seizure; patients with status epilepticus were excluded. Using telephone and mail interviews, participants were followed for 12 months after the acute symptomatic first seizure. Primary endpoint was the occurrence and timing of a first unprovoked seizure relapse. In addition, neuro-intensivists in Germany were interviewed about their antiseizure treatment strategies through an anonymous online survey.

RESULTS

Eleven of 122 participants with structural etiology had an unprovoked seizure relapse, resulting in a cumulative 12-month risk of 10.7% (95%CI, 4.7%-16.7%). None of 19 participants with a non-structural etiology had a subsequent unprovoked seizure. Compared to structural etiology alone, combined infectious and structural etiology was independently associated with unprovoked seizure relapse (OR 11.1; 95%CI, 1.8-69.7). Median duration of antiseizure treatment was 3.4 months (IQR 0-9.3). Seven out of 11 participants had their unprovoked seizure relapse while taking antiseizure medication; longer treatment durations were not associated with decreased risk of unprovoked seizure relapse. Following the non-representative online survey, most neuro-intensivists consider 3 months or less of antiseizure medication to be adequate.

CONCLUSIONS

Even in case of structural etiology, acute symptomatic seizures bear a low risk of subsequent unprovoked seizures. There is still no evidence favoring long-term treatments with antiseizure medications. Hence, individual constellations with an increased risk of unprovoked seizure relapse should be identified, such as central nervous system infections causing structural brain damage. However, in the absence of high-risk features, antiseizure medications should be discontinued early to avoid overtreatment.

Bilateral Anterior Shoulder Dislocations Following a Clozapine-Induced Seizure

Posterior shoulder dislocations are a recognised complication of generalised seizure episodes. Although less frequent, anterior shoulder dislocations are now being acknowledged as an emerging consequence. Particularly when they occur bilaterally, they can contribute to diagnosing a seizure disorder in a patient who shows no other signs during the post-ictal period. This article presents a case of bilateral anterior shoulder dislocations in an otherwise physically healthy young Sudanese gentleman following a generalised seizure episode on clozapine for a schizoaffective disorder. The case aims to raise awareness of the occurrence of this phenomenon and emphasises the importance of timely diagnostic testing, seizure prophylaxis, and follow-up to minimise the risk of further seizure episodes and potential consequences. Additionally, there is a discussion regarding the utility of monitoring clozapine concentrations.

Acute Abortive Therapies for Seizure Clusters in Long-Term Care

OBJECTIVES

To describe acute seizure treatment for the long-term care setting, emphasizing rescue (acute abortive) medications for on-site management of acute unexpected seizures and seizure clusters.

DESIGN

Narrative review.

SETTING AND PARTICIPANTS

People with seizures in long-term care, including group residences.

METHODS

PubMed was searched using keywords that pertained to rescue medications, seizure emergencies/epilepsy, seizure action plans, and long-term care.

RESULTS

Seizure disorder, including epilepsy, is prevalent in long-term care residences, and rescue medications can be used for on-site treatment. Diazepam rectal gel, intranasal midazolam, and diazepam nasal spray are US Food and Drug Administration (FDA)-approved seizure-cluster rescue medications, and intravenous diazepam and lorazepam are approved for status epilepticus. Benzodiazepines differ by formulation, route of administration, absorption, and metabolism. Intranasal formulations are easy and ideal for public use and when rectal treatment is challenging (eg, wheelchair). Intranasal, intrabuccal, and rectal formulations do not require specialized training to administer and are easier for staff at all levels of training compared with intravenous treatment. Off-label rescue medications may have anecdotal support; however, potential disadvantages include variable absorption and onset of action as well as potential risks to patients and caregivers/care partners. Delivery of intravenous-administered rescue medications is delayed by the time needed to set up and deliver the medication and is subject to dosing errors. Seizure action plans that include management of acute seizures can optimize the quality and timing of treatment, which may reduce emergency service needs and prevent progression to status epilepticus.

CONCLUSIONS AND IMPLICATIONS

Seizure disorder is prevalent across all ages but is increased in older adults and in those with intellectual and developmental disabilities. Prompt intervention may reduce negative outcomes associated with acute unexpected seizures and seizure clusters. Seizure action plans that include acute seizures can improve the treatment response by detailing the necessary information for staff to provide immediate treatment.

Efficacy of bedside optic nerve sheath diameter measurement in differentiating provoked seizure from unprovoked seizure in the emergency department

BACKGROUND

Emergency departments (EDs) are typically the first medical contact for seizure patients, and early diagnosis and treatment is primarily the responsibility of emergency physicians.

OBJECTIVES

Demonstrate the efficacy of bedside ocular ultrasonography for optic nerve sheath diameter (ONSD) measurement in differentiating provoked seizure from unprovoked seizure in the ED.

DESIGN

Prospective observational study SETTINGS: Tertiary care hospital PATIENTS AND METHODS: Patients presenting to the ED with seizure were divided into two groups according to medical history, physical examination, laboratory results, cranial computed tomography findings and electroencephalography results. Patients with seizures that did not have a specific cause (unprovoked) were compared with patients who had seizures caused by underlying pathology (provoked). The measurement of the ONSD was taken at the bedside within 30 minutes of arrival. The study compared the ONSD values, age, sex, type of seizure, and Glasgow Coma Score between the two groups.

MAIN OUTCOME MEASURE

Efficacy of ONSD to distinguish between provoked and unprovoked seizures.

SAMPLE SIZE

210 patients RESULTS: One hundred and fourteen (54.3%) patients were in the provoked seizure group and 96 (45.7%) were in the unprovoked seizure group. The ONSD measurements were significantly higher in the provoked seizure group compared with the unprovoked seizure group (median 6.1 mm vs. 5.2 mm, P<.001). The cut-off value of ONSD higher than 5.61 was significantly associated with the prediction of the provoked seizure (P<.001). The area under the curve value was 0.882 (95% CI: 0.830-0.922) with a sensitivity of 86.5 and specificity of 78.9%.

CONCLUSIONS

Bedside ONSD measurement by means of ocular ultrasound is an effective method for differentiating provoked seizure from unprovoked seizure.

LIMITATIONS

Statistical significance of age on ONSD and exclusion of pediatric patients.

CONFLICT OF INTEREST

None.

ES-RED (Early Seizure Recurrence in the Emergency Department) Calculator: A Triage Tool for Seizure Patients

Seizure is a common neurological presentation in patients visiting the emergency department (ED) that requires time for evaluation and observation. Timely decision and disposition standards for seizure patients need to be established to prevent overcrowding in the ED and achieve patients’ safety. Here, we conducted a retrospective cohort study to predict early seizure recurrence in the ED (ES-RED). We randomly assigned 688 patients to the derivation and validation cohorts (2:1 ratio). Prediction equations extracted routine clinical and laboratory information from EDs using logistic regression (Model 1) and machine learning (Model 2) methods. The prediction equations showed good predictive performance, the area under the receiver operating characteristics curve showing 0.808 in Model 1 [95% confidential interval (CI): 0.761–0.853] and 0.805 in Model 2 [95% CI: 0.747–0.857] in the derivation cohort. In the external validation, the models showed strong prediction performance of 0.739 [95% CI: 0.640–0.824] in Model 1 and 0.738 [95% CI: 0.645–0.819] in Model 2. Intriguingly, the lowest quartile group showed no ES-RED after 6 h. The ES-RED calculator, our proposed prediction equation, would provide strong evidence for safe and appropriate disposition of adult resolved seizure patients from EDs, reducing overcrowding and delays and improving patient safety.

Association between benzodiazepine outpatient treatment and risk of early seizure recurrence in emergency patients with seizure: A multicenter retrospective study

INTRODUCTION

Seizures are one of the most common neurological reasons for emergency department (ED) visits. The benefit of ED-initiated, short-course outpatient benzodiazepine (BZD) treatment to prevent early recurrent seizure is unknown. This study assesses the risk of early seizure recurrence in patients who were or were not started with outpatient BZD in the ED.

METHODS

This was a multicenter retrospective study conducted in eight French EDs between January 1 and December 31, 2019. All patients admitted for seizure were retrospectively screened and those discharged home from the ED were included. Patients with a history of chronic alcohol intoxication or chronic BZD therapy were excluded. Baseline characteristics, type of seizure, and 30-day outcome were retrospectively collected from the electronic health records. The primary endpoint was a return visit for seizure recurrence within 30 days. Independent factors associated with a seizure recurrence were identified using a multivariable binary logistic regression.

RESULTS

A total of 2,218 patients were included and 1,820 were analyzed. The median age was 39 years and 60% were men. Among them 82% of patients had a generalized tonic-clonic seizure and 47% of seizures were idiopathic. BZD treatment was started in 773 (42%) patients. A total of 154 (8%) patients had an early recurrence at 30 days: 68 (9%) in patients who were treated with BZD versus 86 (8%) in patients who were not (odds ratio [OR] = 1.07, 95% confidence interval [CI] = 0.71 to 1.43). In multivariable analysis, two factors were independently associated with the primary endpoint: chronic epileptic treatment (adjusted OR = 2.58, 95% CI = 1.55 to 4.37) and having had a focal seizure (adjusted OR = 2.16, 95% CI = 1.56 to 4.37).

CONCLUSION

BZD therapy was started in 42% of patients who were discharged home after ED visit for a seizure. This treatment was not an independent factor associated with the risk of return visit for seizure recurrence at 30 days.

Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update

PURPOSE

To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy.

SUMMARY

Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma.

CONCLUSION

There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.

A systematic literature review of recommendations for referral to specialty care for patients with epilepsy

OBJECTIVE

In epilepsy, patients who receive appropriate care receive treatment that differs substantially from those that do not. Given the need for a more detailed assessment of the role of specialty referral in the care of patients with epilepsy, this systematic literature review identified epilepsy care guidelines and recommendations that specifically address when and why people with epilepsy should be referred to specialty care.

METHODS

This study identified recent (in the last 10 years) publications that made best-practice recommendations for referring people with epilepsy to a neurologist or epileptologist. We searched six databases in December 2018: MEDLINE (PubMed), Cochrane Library, ProQuest, Web of Science, CINAHL (Ebsco), Scopus (Elsevier). Search terms included "Epilepsy" OR "Seizures," "Guideline" OR "Practice Parameter," and "Referral."

RESULTS

The 15 full-text articles identified included formal guidelines, summaries of these guidelines, or professional commentary that builds upon existing guidelines. Most of these publications came from the U.K and its National Institute for Health and Care Excellence. Overall, the included recommendations for referral varied considerably both for new-onset and refractory epilepsy. Although these recommendations were not consistent, it is reasonable to refer patients following the failure of 2 anti-seizure medication (ASM) trials.

SIGNIFICANCE

Guidelines and informal recommendations are not consistent regarding best practices for specialty care referral for patients with epilepsy. These guidelines and recommendations should consider the context of care in real-world settings and suggest pragmatic approaches that optimize seizure control and functioning.

Identification of Predictors of Abnormal Calcium, Magnesium and Phosphorus Blood Levels in the Emergency Department: A Retrospective Cohort Study

Purpose

With rising healthcare costs limiting access to care, the judicious use of diagnostic tests has become a critical issue for many jurisdictions. Calcium, magnesium and phosphorus serum levels are regularly performed tests in the emergency department, but their clinical relevance have come into question. Authors sought to determine risk factors that could predict abnormal calcium, magnesium and phosphorus serum levels, as well as identify patients who may need corrective interventions.

Methods

A retrospective cohort study was conducted in two academic hospitals in Québec City. Demographic and clinical characteristics of 1008 patients who had serum calcium and/or magnesium and/or phosphorus levels drawn by an emergency physician were collected. Multivariate logistic regression models were fitted to obtain adjusted odds ratios for each risk factor for abnormal calcium or magnesium or phosphorus blood levels, and for a required intervention.

Results

Among patients for whom calcium, magnesium and phosphorus were tested in the Emergency Department, the most significant risk factors (OR>2) for electrolytic abnormality were as follows: hypocalcemia – respiratory distress, diuretics (excluding loop and thiazide), anti-neoplastic medication, long QTc, chronic kidney disease (CKD); hypercalcemia – bone pain, vitamin D, hallucinations; hypomagnesemia – diabetes, corticosteroids; hypermagnesemia – poor extremity perfusion, CKD, furosemide; hypophosphatemia – seizure; hyperphosphatemia – phosphate-binders, CKD, peripheral vascular atherosclerotic disease. Of all patients tested, 3.4% received a corrective intervention initiated by the emergency physician. Predictors of intervention on an electrolyte abnormality include poor peripheral perfusion, nausea and chronic obstructive pulmonary disease (COPD).

Conclusion

Emergency physicians can potentially reduce the unnecessary testing of calcium, magnesium and phosphorus blood levels by targeting patients with high-acuity conditions or chronic comorbidities such as CKD, diabetes and COPD.

Clinical characteristics of 30 COVID-19 patients with epilepsy: A retrospective study in Wuhan

Objective

This study aims to present the clinical characteristics of 30 hospitalized cases with epileptic seizures and coronavirus disease 2019(COVID-19).

Methods

This is a retrospective observational research study. Clinical data were extracted from electronic medical records in 1550 patients with a laboratory-confirmed diagnosis of COVID-19, who were hospitalized in Wuhan Central Hospital, China, from 1 January to 31 April 2020. 30 COVID-19 patients with the diagnosis of epilepsy were enrolled. The clinical characteristics, complications, treatments, and clinical outcomes of 30 cases were collected and analyzed.

Result

Of 30 patients with a diagnosis of epilepsy and COVID-19, 13 patients (43.4%) had new-onset epileptic seizures without an epilepsy history(new-onset seizure group, NS group), ten patients(33.3%) had an epilepsy history with a recurrent epileptic seizure (recurrent seizure group, RS group) and seven patients(23.3%) had an epilepsy history but no seizure during the course of COVID-19 (epilepsy history group, EH group). Patients in the RS group had a larger number of other-neurological-disease histories than those in the NS and EH groups (7/10[70%] VS 1/13 [7.7%] VS 1/7[14.3%]); the difference between the RS group and NS group is significant (P < 0.05). Patients in the NE and RS groups suffered more severe/critical COVID-19 infection than patients in the EH group (10/13[76.9%] VS 6/10[60%] VS 1/7[14.3%]); the difference between the NS group and EH group is significant (P < 0.05). 36.7% of patients had one to five neurological complications, and 46.4% of patients had 6–10 neurological complications. The complications in patients with seizures (in the RS and NS groups) seem to be more than those without seizures (in the EH group), but it did not reach statistical significance. The proportion of antiepileptic drugs (AEDs) treatment before admission was higher in the EH group than in the RE group(7/7 [100%] VS 2/10 [20%], P < 0.05). The mortality of 30 patients with epilepsy and COVID-19 was 36.67%. The mortality of the NS group(38.5%) and the RS group(50%) were a little higher than in the EH group(14.3%). None of the convalescent patients had a recurrent seizure, and there were no more deaths in the 3-month follow-up after discharge.

Conclusions

COVID-19 patients with recurrent epileptic seizures had more underlying neurological diseases than patients who had an epilepsy history but without a seizure. Patients with new-onset and recurrent epileptic seizures suffered more severe/critical COVID-19, which may lead to a worse prognosis. If patients with epilepsy history continue using AEDs during COVID-19 pandemics, the risk of recurrent seizure may be reduced, and a good prognosis for patients with epilepsy history could be expected.

Evaluation of ubiquitin C-terminal hydrolase-L1 enzyme levels in patients with epilepsy

OBJECTIVE

Ubiquitin C-terminal Hydrolase-L1 (UCH-L1) enzyme levels were investigated in patients with epilepsy, epileptic seizure, remission period, and healthy individuals.

METHODS

Three main groups were evaluated, including epileptic seizure, patients with epilepsy in the non-seizure period, and healthy volunteers. The patients having a seizure in the Emergency department or brought by a postictal confusion were included in the epileptic attack group. The patients having a seizure attack or presenting to the Neurology outpatient department for follow up were included in the non-seizure (remission period) group.

RESULTS

The UCH-L1 enzyme levels of 160 patients with epilepsy (80 patients with epileptic attack and 80 patients with epilepsy in the non-seizure period) and 100 healthy volunteers were compared. Whereas the UCH-L1 enzyme levels were 8.30 (IQR=6.57‒11.40) ng/mL in all patients with epilepsy, they were detected as 3.90 (IQR=3.31‒7.22) ng/mL in healthy volunteers, and significantly increased in numbers for those with epilepsy (p<0.001). However, whereas the UCH-L1 levels were 8.50 (IQR=6.93‒11.16) ng/mL in the patients with epileptic seizures, they were 8.10 (IQR=6.22‒11.93) ng/mL in the non-seizure period, and no significant difference was detected (p=0.6123). When the UCH-L1 cut-off value was taken as 4.34 mg/mL in Receiver Operating Characteristic (ROC) Curve analysis, the sensitivity and specificity detected were 93.75 and 66.00%, respectively (AUG=0.801; p<0.0001; 95%CI 0.747‒0.848) for patients with epilepsy.

CONCLUSION

Even though UCH-L1 levels significantly increased more in patients with epilepsy than in healthy individuals, there was no difference between epileptic seizure and non-seizure periods.

Neuroimaging of first seizure in the adult emergency patients

The aim is to establish the role of head computed tomography (CT) and magnetic resonance imaging (MRI) in adults presenting to the emergency department (ED) with first-time seizure (FS) and to analyze the potential predictor variables for the adverse imaging outcome. We retrospectively reviewed the medical records of all adults who underwent cranial CT or MRI between January 1, 2011, and December 1, 2016, to an academic ED for FS. Patients were excluded if were under 18 years of age, had known recent intracranial pathology, known brain tumor or having a history of trauma. Important predictive variables to indicate pathology in either CT or MR scan in patients with FS were evaluated with logistic regression analysis. A total of 546 FS (293 men and 253 women; range, 18-81 years; mean, 47 years) were identified in patients receiving either cranial CT or MR scan. Of them, abnormal findings were observed in 22/451 (4.8%) patients on CT and 18/95 (18.9%) patients on MRI. Predictor variables of age greater than 50 years, focal neurologic deficit, hypoglycemia, and history of malignancy were identified on CT, whereas a history of malignancy, age greater than 50 years and focal neurological deficit were determined on MRI. Limiting neuroimaging to this population would potentially reduce head CT scans by 67% and would potentially reduce head MRI scans by 47%. Clinical suspicion should be heightened and the neuroimaging should be considered for advanced age, history of malignancy, hypoglycemia or focal neurological deficits in patients with FS.

Brain CT Findings in Patients with First-Onset Seizure Visiting the Emergency Department in Mashhad, Iran

Introduction

Regarding the complications and costs of CT imaging for patients, this study aimed at investigating the necessity of CT scans in patients visiting the emergency unit with first-onset seizure.

Methods

One hundred patients who had experienced their first seizure were enrolled. Their CT scan was studied, and based on the radiology report, the type of probable pathologies and their percentage were determined.

Results

The patient’s mean age was 39.78±17.43 yrs. CT scan abnormalities were reported in 27 cases as follows: nonspecific senile changes in 11 (40.7%), encephalomalacia in 3 (11.1%), acute infarct in 5 (18.5%), lacunar infarct in 3 (11.1%), mass-like lesion in 4 (14.8%) and cerebral venous thrombosis (CVT) evidence in 1 (3.7%). Acute infarct and mass-like lesions were seen together in the CT scan of one patient. In only 9 of the 27 abnormal CT scans, the findings were in accordance with seizure consisting of an acute infarct, mass-like lesion, and CVT evidence.

Discussion

It seems that performing a CT scan in all patients referring to the emergency department with a first-onset seizure is not necessary.

High-Risk Chief Complaints III: Neurologic Emergencies

A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims.

Learning in the Digital Era - Awareness and Usage of Free Open Access Meducation among Emergency Department Doctors

Introduction

Information and communication technology has revolutionized the space of medical education by providing a multitude of up-to-date evidence-based data to healthcare practitioners. Despite the increasing popularity of FOAM - Free Open Access Meducation (Medical Education) globally - data relating to its awareness and usage in Africa is lacking. In this study, we explore the awareness and usage of FOAM among doctors working at select emergency departments in Johannesburg.

Methods

The study comprised a prospective, questionnaire based, cross-sectional survey of medical doctors working at five academically affiliated emergency departments in Johannesburg. Data was described and compared.

Results

One-hundred and four participants completed the survey. Most of the respondents were aged between 31 and 39 years (n = 40, 43.9%). There were no significant differences between the proportion of females and males that used FOAM (p = 0.56). Most participants (n = 91, 87.5%) were aware of FOAM, while 82 (78.8%) used FOAM, 13 (12.5%) were unsure if they used FOAM and nine (8.7%) did not use FOAM. Majority of those that used FOAM, only used it once a week (n = 47, 57.3%). Most participants spent between one and two hours per day on FOAM (n = 29, 35.4%). Smartphones were by far the most commonly used device to access FOAM (n = 91, 87.5%).

Conclusion

The level of awareness of FOAM is high and its usage is prevalent among emergency medicine healthcare professionals in Johannesburg. As technology becomes more prominent, institutions must aim to adapt to the digital era in their teaching methods.

Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP)

BACKGROUND

falls, seizures, syncope and transient ischaemic attacks (TIA) are common presentations to emergency departments sharing overlapping clinical features and diagnostic uncertainties. These transient attacks can be markers of serious adverse outcomes and are associated with high admission rates. We evaluated the effects of an integrated suite of pathways for transient attacks designed to improve adherence to best practices and reduce costs through fewer admissions.

METHODS

a suite of clinician-designed pathways based on initial presenting diagnosis was developed to support ambulant care in a large hospital in Queensland, Australia. We performed a set of regression analyses to identify the differences in total cost and length of stay (LOS) before and after implementation. We conducted a Monte Carlo simulation to estimate the cost savings of the freed capacity in the patient cohort.

RESULTS

pathway implementation was associated with reduced admitted LOS and costs. Falls patients admitted LOS declined by 32.5%, and admission costs by 19.5%. Syncope, seizure, and TIA patients admitted LOS declined by 22% with no change in admitted costs. Despite a small increase in 90-day representations, total emergency department LOS was unchanged. Emergency department costs were similar between falls and non-falls patients. The Monte Carlo analysis showed that the most likely outcome was a cost savings in freed capacity of $71 per patient episode.

CONCLUSION

the ATAP suite of pathways was associated with reduction in LOS, release of capacity and reduction in costs. Further study is needed to evaluate mechanisms and clinical outcomes in this vulnerable population.

Delayed diagnosis of long QT syndrome in a patient with seizures

Introduction:

Long QT syndrome accompanied by a seizure episode is often misdiagnosed as primary epilepsy. Although patients with Long QT syndrome who are misdiagnosed and improperly managed are likely to result in fatality, their first clinical manifestations are seizure episodes in many cases.

Case presentation:

A 17-year-old boy visited the emergency department with poorly controlled seizure during epilepsy treatment was found to have been misdiagnosed with epilepsy when he was 7 years old. His electrocardiography showed a prolonged QT interval. After careful re-evaluation, he was finally diagnosed with Long QT syndrome and recovered without any seizure episodes in the absence of anti-epileptic agents.

Discussion and conclusion:

Careful initial assessment including repetitive electrocardiography, when abnormal, is required for those who visit the emergency department with a seizure or who show no definite abnormalities in diagnostic work up process.

Management of Adult Patients in the Pediatric Emergency Department

Adult patients often present to the pediatric emergency department (ED) for treatment of a wide variety of diseases. However, pediatric emergency medicine physicians are primarily trained to provide specialized care for children. Studies have shown that the number of adult patients presenting to pediatric EDs has increased significantly since the introduction of the Emergency Medicine Transfer and Active Labor Act in 1986. This article discusses the management of common adult complaints presenting to the pediatric ED. The focus is on stabilization in the pediatric ED and safe transfer to a more appropriate facility.

Patient-centered outcomes: a qualitative exploration of patient experience with electroencephalograms in the Emergency Department

The primary objective of this qualitative project was to understand the experience of patients who had first-time seizures and who did, and did not, have electroencephalograms (EEGs) performed in the Emergency Department (ED) as part of their initial evaluation, so as to refine the diagnostic and therapeutic approach to these patients and transform the standard of care for first-time seizures by focusing on outcomes as defined by patient experiences and expectations. In this paper, we show that, regardless of the diagnostic and therapeutic approach patients are given in the ED, patients and caregivers trust that health care providers will perform the standard of care consistent with the current medical practice for first-time seizures. However, performing EEGs in the ED and initiating appropriate anticonvulsant therapy for those patients who are at high risk for future seizures addresses patient needs by offering patients a sense of security and control over their medical condition and expediting appropriate follow up care, as long as clearly stated written diagnostic, treatment, and referral instructions are provided upon discharge.

Systematic review of emergency medicine clinical practice guidelines: Implications for research and policy

Introduction

Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence.

Methods

Systematic review of clinical practice guidelines (Clinical Policies) published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies.

Results

A total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent.

Conclusions

Emergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality standards.

An Emergency Medicine-Focused Review of Seizure Mimics

BACKGROUND

Seizures result in a change in motor, sensory, and behavioral symptoms caused by abnormal neurologic electrical activity. The symptoms share similar presentations of several other conditions, leading to difficulties in diagnosis and frequent improper management.

OBJECTIVE

This review evaluates adult patients with suspected seizure, signs and symptoms of seizure, mimics of seizure, and an approach to management of seizure mimics.

DISCUSSION

A seizure is caused by abnormal neurologic electrical activity resulting in altered motor, sensory, and behavioral symptoms. Other conditions may present similarly, causing a challenge in diagnosis. These conditions include syncope, psychogenic nonepileptic seizures, stroke or transient ischemic attack, sleep disorders, movement disorders, and migraines. Diagnosis of seizures in the emergency department (ED) is often clinical. Differentiation between seizures and other conditions can be difficult. Laboratories and imaging provide little benefit in definitive diagnosis in the emergency setting. For patients that have an apparent seizure, resuscitation and management is precedent while identifying any provoking factors and treatment of those factors. For adults recovering from suspected seizure, the combination of a focused history, physical examination, and additional studies can provide assistance in diagnosis.

CONCLUSIONS

Patients with an apparent seizure should be resuscitated with identification of provoking factors. Many conditions can mimic seizures. A focused history, physical examination, and additional studies will assist in differentiating seizures from mimics.

Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

The aim of our study was to identify all previously reported cases of phenytoin- or fosphenytoin-associated purple glove syndrome (PGS) and summarize the most current understanding of the pathophysiology, clinical presentation, diagnosis, and treatment of the disease. We searched the English language references from MEDLINE, EMBASE, CINAHL, TOXNET, and gray literature that featured one or more case descriptions of phenytoin- or fosphenytoin-associated PGS after administration and provided information on the clinical setting of the event and associated outcome(s). Descriptive statistics were employed to summarize relevant facts about the cases. We identified 82 unique cases of parenteral phenytoin-associated PGS and 5 cases of fosphenytoin-associated PGS that were published from 1984 to 2015. Additionally, we found two cases of PGS associated with oral formulation of phenytoin published from 1999 to 2015. The spectrum of tissue injury ranged from mild local cutaneous reactions around the infusion site to frank limb ischemia. Just over a half of cases reported symptoms after one dose of IV phenytoin. Pathologic findings included evidence for microvascular thrombosis and possible microvascular or subclinical extravasation as a contributing mechanism. Dopper ultrasound and conventional angiography were used in some patients to identify arterial or venous thrombosis. Various treatments were documented including the use of supportive care such as limb elevation and heat or cold application, utilization of systemic antibiotics, anticoagulants, or vasodilators, and local infiltration of hyaluronidase, heparin, or other compounds. In a small number of patients, invasive interventions such as regional anesthesia, thrombectomy, fasciotomy, and debridement were described. Time to resolution varied from days to weeks. Resolution of PGS without deficits was documented in the majority of cases. Skin changes followed by sensory and motor deficits were described in 16, 6, and 5 cases, respectively. Four patients underwent skin grafting and eight patients required limb amputation. Death as a result of PGS was documented in two patients. PGS associated with oral and injectable phenytoin or parenteral fosphenytoin has been documented in the literature and sometimes includes significant vascular thrombosis and potentially limb-threatening ischemia. Avoidance of small hand veins, adherence to recommended IV administration guidelines and monitoring of the infusion site for reactions should be considered to decrease the morbidity of IV phenytoin or fosphenytoin use. Patients with PGS and evidence of decreased distal perfusion should undergo prompt vascular imaging and potential intervention to avoid ischemic sequelae. Alternative anticonvulsant drugs should be considered in patients at risk for PGS when possible.

Status Epilepticus: What's New?

The emergent evaluation and treatment of generalized convulsive status epilepticus presents challenges for emergency physicians. This disease is one of the few in which minutes can mean the difference between life and significant morbidity and mortality. It is imperative to use parallel processing and have multiple treatment options planned in advance, in case the current treatment is not successful. There is also benefit to exploring, or initiating, treatment algorithms to standardize the care for these critically ill patients.

Adult Status Epilepticus: A Review of the Prehospital and Emergency Department Management

Seizures are a common presentation in the prehospital and emergency department setting and status epilepticus represents an emergency neurologic condition. The classification and various types of seizures are numerous. The objectives of this narrative literature review focuses on adult patients with a presentation of status epilepticus in the prehospital and emergency department setting. In summary, benzodiazepines remain the primary first line therapeutic agent in the management of status epilepticus, however, there are new agents that may be appropriate for the management of status epilepticus as second- and third-line pharmacological agents.

Knowledge Translation and Barriers to Imaging Optimization in the Emergency Department: A Research Agenda

Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference. We identified the following four overarching research questions: 1) what determinants (barriers and facilitators) influence emergency physicians' use of evidence-based interventions when ordering imaging in the ED; 2) what implementation strategies at the institutional level can improve the use of evidence-based interventions for ED imaging; 3) what interventions at the health care policy level can facilitate the adoption of evidence-based interventions for ED imaging; and 4) how can health information technology, including electronic health records, clinical decision support, and health information exchanges, be used to increase awareness, use, and adherence to evidence-based interventions for ED imaging? Advancing research that addresses these questions will provide valuable information as to how we can use evidence-based interventions to optimize imaging utilization and ultimately improve patient care.

Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine

Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.

Structural MRI biomarkers of shared pathogenesis in autism spectrum disorder and epilepsy

Etiological factors that contribute to a high comorbidity between autism spectrum disorder (ASD) and epilepsy are the subject of much debate. Does epilepsy cause ASD or are there common underlying brain abnormalities that increase the risk of developing both disorders? This review summarizes evidence from quantitative MRI studies to suggest that abnormalities of brain structure are not necessarily the consequence of ASD and epilepsy but are antecedent to disease expression. Abnormal gray and white matter volumes are present prior to onset of ASD and evident at the time of onset in pediatric epilepsy. Aberrant brain growth trajectories are also common in both disorders, as evidenced by blunted gray matter maturation and white matter maturation. Although the etiological factors that explain these abnormalities are unclear, high heritability estimates for gray matter volume and white matter microstructure demonstrate that genetic factors assert a strong influence on brain structure. In addition, histopathological studies of ASD and epilepsy brain tissue reveal elevated rates of malformations of cortical development (MCDs), such as focal cortical dysplasia and heterotopias, which supports disruption of neuronal migration as a contributing factor. Although MCDs are not always visible on MRI with conventional radiological analysis, quantitative MRI detection methods show high sensitivity to subtle malformations in epilepsy and can be potentially applied to MCD detection in ASD. Such an approach is critical for establishing quantitative neuroanatomic endophenotypes that can be used in genetic research. In the context of emerging drug treatments for seizures and autism symptoms, such as rapamycin and rapalogs, in vivo neuroimaging markers of subtle structural brain abnormalities could improve sample stratification in human clinical trials and potentially extend the range of patients that might benefit from treatment. This article is part of a Special Issue entitled "Autism and Epilepsy".

Predictive value of S100-B and copeptin for outcomes following seizure: the BISTRO International Cohort Study

Objective

To evaluate the performance of S100-B protein and copeptin, in addition to clinical variables, in predicting outcomes of patients attending the emergency department (ED) following a seizure.

Methods

We prospectively included adult patients presented with an acute seizure, in four EDs in France and the United Kingdom. Participants were followed up for 28 days. The primary endpoint was a composite of seizure recurrence, all-cause mortality, hospitalization or rehospitalisation, or return visit in the ED within seven days.

Results

Among the 389 participants included in the analysis, 156 (40%) experienced the primary endpoint within seven days and 195 (54%) at 28 days. Mean levels of both S100-B (0.11 μg/l [95% CI 0.07–0.20] vs 0.09 μg/l [0.07–0.14]) and copeptin (23 pmol/l [9–104] vs 17 pmol/l [8–43]) were higher in participants meeting the primary endpoint. However, both biomarkers were poorly predictive of the primary outcome with a respective area under the receiving operator characteristic curve of 0.57 [0.51–0.64] and 0.59 [0.54–0.64]. Multivariable logistic regression analysis identified higher age (odds ratio [OR] 1.3 per decade [1.1–1.5]), provoked seizure (OR 4.93 [2.5–9.8]), complex partial seizure (OR 4.09 [1.8–9.1]) and first seizure (OR 1.83 [1.1–3.0]) as independent predictors of the primary outcome. A second regression analysis including the biomarkers showed no additional predictive benefit (S100-B OR 3.89 [0.80–18.9] copeptin OR 1 [1.00–1.00]).

Conclusion

The plasma biomarkers S100-B and copeptin did not improve prediction of poor outcome following seizure. Higher age, a first seizure, a provoked seizure and a partial complex seizure are independently associated with adverse outcomes.

The benefits of antiepileptic drug (AED) blood level monitoring to complement clinical management of people with epilepsy

INTRODUCTION

Some argue that there is no evidence to support the use of antiepileptic drug (AED) blood level monitoring when treating people with epilepsy (PWE). This paper identifies how AED monitoring can be invaluable in such treatment. SPECIFIC EXAMPLES: (i) Compliance: Antiepileptic drug blood levels often confirm noncompliance rather than adequate seizure control, confirming subtherapeutic levels in PWE attending hospitals due to seizures. Routine monitoring of AED levels may prevent breakthrough seizures by identifying noncompliance and instituting heightened compliance measures before experiencing breakthrough seizures without modifying dosages. For PWE attending hospitals due to seizures, loading with the AED shown to be subtherapeutic may be all that is required. (ii) Cluster seizures and status epilepticus: When using long-acting AEDs to complement benzodiazepines, blood level monitoring confirms that an adequate dosage was given and, if not, a further bolus can be administered with further monitoring. This is particularly useful when using rectal administration of AEDs. (iii) Polypharmacy: Polypharmacy provokes drug interactions in which case AED monitoring helps in differentiating adequate dosing, offending AED with toxicity and free level measuring benefits when total levels are unhelpful. (iv) Generic substitution: Generic AEDs can fluctuate considerably from a parent compound, and even a parent compound, sourced from an alternative supplier, may have altered bioavailability for which blood level monitoring is very useful.

CONCLUSIONS

While therapeutic blood level monitoring is not a substitute for good clinical judgment, it offers a valuable adjunct to patient care.

Computed tomography abnormalities and epidemiology of adult patients presenting with first seizure to the emergency department in Qatar

OBJECTIVES

There is little information available from the Middle Eastern region on adult patients presenting with first seizure. The objectives of this study were to describe epidemiological characteristics of patients presenting to the emergency department (ED) in Doha, Qatar, with first seizure and to determine the incidence of computed tomographic (CT) scan abnormalities.

METHODS

A retrospective cohort study was conducted on all adult patients with first seizure presenting to Hamad General Hospital ED over a 1-year period (June 2012 through May 2013). Electronic patient records were reviewed for demographics, neuroimaging, electroencephalography, laboratory test results, and medications administered.

RESULTS

There were 439 patients who satisfied inclusion criteria. Patients were aged a mean of 35.3 years (95% confidence interval [CI] = 33.92 to 36.69 years) with a male-to-female ratio of five to one. CT abnormalities were detected in 154 patients (35.3%; 95% CI = 30.81% to 39.82%). Out of reported abnormal scans, 14.7% patients had significant abnormalities such as neurocysticercosis (9.2%); brain metastasis and neoplasm (3.4%); and subarachnoid and subdural hemorrhage, cavernous sinus thrombosis, acute stroke, and brain edema (2.0%). None of the patients had any electrolyte abnormalities, and three patients had hypoglycemia. Patients with initial abnormal CT brain results were more likely to have recurrent seizures (OR = 1.65; 95% CI = 1.11 to 2.45) within 6 months.

CONCLUSIONS

Adults who presented with first seizure to the ED in Qatar had a young male predominance, and a high proportion of brain CT scans were reported as abnormal. It is recommended that all such patients in this population should undergo prompt CT scanning in the ED, but the utility of routine electrolyte tests requires further investigation.

Chief complaint-based performance measures: a new focus for acute care quality measurement

Performance measures are increasingly important to guide meaningful quality improvement efforts and value-based reimbursement. Populations included in most current hospital performance measures are defined by recorded diagnoses using International Classification of Diseases, Ninth Revision codes in administrative claims data. Although the diagnosis-centric approach allows the assessment of disease-specific quality, it fails to measure one of the primary functions of emergency department (ED) care, which involves diagnosing, risk stratifying, and treating patients' potentially life-threatening conditions according to symptoms (ie, chief complaints). In this article, we propose chief complaint-based quality measures as a means to enhance the evaluation of quality and value in emergency care. We discuss the potential benefits of chief complaint-based measures, describe opportunities to mitigate challenges, propose an example measure set, and present several recommendations to advance this paradigm in ED-based performance measurement.