The Emergency Department Evaluation of the Adult Patient Who Presents with a First-Time Seizure

Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required.

We retrospectively studied patients aged ≥16 years who presented to the emergency department with complaints of seizures and fever above 37.5 °C who were admitted to the hospital between January 2017 and December 2019. LP was performed when the emergency physician suspected meningitis or encephalitis. Neurologists assessed patients with normal cerebrospinal fluid (CSF) findings and those admitted without LP after hospitalization. A neurologist confirmed the diagnoses of meningitis and encephalitis.

The study included 148 patients. Ninety-seven patients (65.5%) were male, and the median age was 60 years. LP was performed in 105 patients (70.9%), and 14 (13.4%) had CSF pleocytosis. Meningitis and encephalitis were diagnosed in nine patients (6.1%), of whom four (2.8%) had CNS infections. Patients diagnosed with meningitis and encephalitis were more likely to have Glasgow Coma Scale <13 (P = 0.03) and less likely to have a history of seizures or epilepsy (P = 0.04) and had higher C-reactive protein levels than the other patients (P = 0.02).

The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.

Neuroimaging in geriatric patients presenting to the emergency department can be critical, as older patients tend to have atypical presentation of diseases with nonspecific signs and symptoms, which often delay diagnosis. Clinicians and radiologists should become familiar with imaging indications and imaging findings of acute conditions in geriatric patients, because these patients are more likely to require emergency care, and the number of visits to the emergency departments continues to rise. Noncontrast computed tomography of the head is often the first imaging modality in cases of suspected neurological insult, with follow-up magnetic resonance imaging of the brain in cases of identified pathology or suspected occult pathology, or to confirm a suspected clinical diagnosis. Conditions such as acute stroke, hemorrhage, and seizures are common in the elderly population and are discussed in this chapter. Imaging indications and imaging findings of central nervous system infections, altered mental status, dizziness, and syncope are also reviewed.

Well recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology.

We retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients.

We reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748–0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7–100.0).

A score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results.

Las anteriores Guías oficiales de práctica clínica en epilepsia elaboradas por el Grupo de Estudio de Epilepsia de la Sociedad Española de Neurología (GE-SEN) estaban basadas en la opinión de expertos.

La actual Guía de práctica clínica (GPC) en epilepsia se basa en el método científico que extrae recomendaciones a partir de evidencias científicas constatadas. Su principal función es disminuir la variabilidad de la práctica clínica a través de la homogeneización de la práctica médica.

Esta GPC se centra en la atención integral de personas afectadas por una epilepsia, como síntoma principal y predominante, independiente de la edad de inicio y ámbito asistencial.

1) Constitución del grupo de trabajo integrado por neurólogos del GE-SEN, con la colaboración de neuropediatras, neurofisiólogos y neurorradiólogos; 2) determinación de los aspectos clínicos a cubrir: diagnóstico, pronóstico y tratamiento; 3) búsqueda y selección de la evidencia científica relevante; 4) formulación de recomendaciones basadas en la clasificación de las evidencias científicas disponibles.

Contienen 192 recomendaciones. El 57% son de consenso entre autores y editores, como consecuencia del desconocimiento en muchos campos de esta patología.

Esta GPC, en epilepsia, con una metodología formal y rigurosa en la búsqueda de evidencias explícitas donde ha sido posible, formula recomendaciones extraídas de las mismas.

En este artículo incluimos el capítulo de la GPC dedicado a situaciones de urgencia en crisis epilépticas y epilepsia, que pueden presentarse como una primera crisis epiléptica, una evolución desfavorable en un paciente con una epilepsia conocida o en su forma más grave como un estado epiléptico.

Previous Official Clinical Practice Guidelines (CPGs) in Epilepsy were based on expert opinions and developed by the Epilepsy Study Group of the Spanish Neurological Society (GE-SEN).

The current CPG in epilepsy is based on the scientific method, which extracts recommendations from published scientific evidence. A reduction in the variability in clinical practice through standardization of medical practice has become its main function.

This CPG is focused on comprehensive care for individuals affected by epilepsy as a primary and predominant symptom, regardless of the age of onset and medical policy.

1. Creation of GE-SEN neurologists working group, in collaboration with Neuropediatricians, Neurophysiologists and Neuroradiologists. 2. Identification of clinical areas to be covered: diagnosis, prognosis and treatment. 3. Search and selection of the relevant scientific evidence. 4. Formulation of recommendations based on the classification of the available scientific evidence.

It contains 161 recommendations of which 57% are consensus between authors and publishers, due to an important lack of awareness in many fields of this pathology.

This Epilepsy CPG formulates recommendations based on explicit scientific evidence as a result of a formal and rigorous methodology, according to the current knowledge in the pre-selected areas.

This paper includes the CPG chapter dedicated to emergency situations in seizures and epilepsy, which may present as a first seizure, an unfavorable outcome in a patient with known epilepsy, or status epilepticus as the most severe manifestation.

Las crisis epilépticas comprenden aproximadamente el 1% de las consultas en Urgencias. Los motivos de consulta pueden deberse a: una crisis sintomática aguda debida a algún proceso agudo donde el tratamiento fundamental es el de la causa; pacientes que presentan una primera crisis de causa no provocada donde se deben valorar los factores de riesgo de recurrencia para iniciar un tratamiento antiepiléptico; pacientes con epilepsia conocida que presentan empeoramiento clínico y pacientes con un estatus epiléptico que por su mal pronóstico precisan de un tratamiento adecuado y urgente. Las benzodiacepinas son el tratamiento de primera elección de las crisis prolongadas y de todos los tipos de estados epilépticos.

Seizures comprise approximately 1% of emergency room visits. The reasons for visits to the emergency may be due to: an acute symptomatic seizure due to an acute process where the main treatment is the cause; patients with a first unprovoked crisis because where you should evaluate factors risk of recurrence to start antiepileptic treatment; patients with known epilepsy who presented clinical worsening and patients with status epilepticus by its poor prognosis require adequate and urgent treatment. Benzodiazepines are the treatment of choice of protracted crises and all types of epileptic states.