The new wave: time to bring EEG to the emergency department

Point-of-care EEG in the pediatric emergency department: a systematic review

Central nervous system (CNS) disorders, including seizures, status epilepticus (SE), and altered mental status, constitute a significant proportion of cases presenting in the pediatric emergency department. EEG is essential for diagnosing nonconvulsive SE, but standard EEG is often unavailable due to resource constraints. Point-of-care EEG (pocEEG) has emerged as a viable alternative, offering rapid bedside assessment. This systematic review synthesizes existing data on the use of pocEEG in pediatric emergencies and highlights research gaps. A comprehensive search of PubMed, CINAHL, and EMBASE identified six studies on pediatric populations using simplified EEG montages, with cohort sizes ranging from 20 to 242 patients. The findings indicate that pocEEG is feasible in acute pediatric care, effectively aiding in the detection of nonconvulsive SE and other critical neurological conditions. The studies varied in electrode placement strategies, ranging from neonatal to subhairline montages.

CONCLUSION

Despite some implementation challenges, pocEEG has shown sufficient accuracy for clinical use. Further research should focus on optimizing EEG montages, refining interpretation, and assessing its impact on patient outcomes. This review underscores the potential of pocEEG to address critical care needs in pediatric emergency departments and calls for larger, standardized studies.

WHAT IS KNOWN

•  Central nervous system (CNS) disorders, such as seizures and altered mental status, are common and critical conditions encountered in pediatric emergency resuscitation bays. •  EEG is essential for diagnosing nonconvulsive status epilepticus, but standard EEG is often unavailable in emergency departments due to logistical challenges, limited resources, and the need for specialized interpretation.

WHAT IS NEW

•  Reduced-lead, point-of-care EEG (pocEEG) is a feasible alternative for real-time bedside CNS monitoring in pediatric emergency settings, aiding in the diagnosis of nonconvulsive status epilepticus and guiding the management of convulsive status epilepticus. • This systematic review highlights the feasibility and clinical potential of pocEEG in pediatric emergency departments and identifies key areas for further research, including the development of standardized pocEEG protocols and the integration of automated EEG analysis.

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.

A review of neurological health disparities in Peru

Peru is a historically unique and culturally diverse Latin American country. As a low-to-middle-income country (LMIC), Peru faces health implications from the spread of communicable diseases as well as a growing rate of noncommunicable diseases, both of which have been worsened by the recent COVID-19 pandemic's impact on the national health system. Over the past two decades, the country has aimed to improve health access for its population through various efforts described in this review. Despite this, there are notable neurological health disparities that exist today. This narrative review investigates such disparities through the leading neurological contributors to the national burden of disease in the country, including migraine headaches, cerebrovascular disease, and dementia. Public health disparities that contribute to other major neurological diseases in the country, including epilepsy, neurocysticercosis, Chagas disease, multiple sclerosis, traumatic brain injury, traumatic and non-traumatic spinal cord injuries are also investigated. We also explore potential solutions for overcoming the various neurological health disparities covered in this review that may be applied through public policies, as well as in similar LMICs in Latin America. By overcoming such disparities, the country may be able to successfully address the major contributors of neurological disease burden and create a healthcare environment that can sustainably and equitably improve health outcomes for Peruvian people.

Point-of-care electroencephalography enables rapid evaluation and management of non-convulsive seizures and status epilepticus in the emergency department

Objectives

To describe our institutional experience with point-of-care electroencephalography (pocEEG) and its impact on the evaluation/management of suspected non-convulsive seizures in the emergency department (ED).

Methods

We retrospectively identified 157 adults who underwent pocEEG monitoring in our community hospital ED in 1 year. We calculated the time to obtain pocEEG in the ED (door-to-EEG time) and examined the impact of pocEEG findings (categorized as seizure, highly epileptiform patterns, slowing, or normal activity) on antiseizure medication treatment.

Results

PocEEG revealed seizures (14%, n = 22), highly epileptiform patterns (22%, n = 34), slowing (44%, n = 69), and normal activity (20%, n = 32). The median door-to-EEG time (from initial ED evaluation to pocEEG monitoring) was only 1.2 hours (interquartile range 0.1-2.1) even though 55% of studies were performed after-hours (5 pm-9 am). Most patients were admitted (54% to the intensive care unit, 41% to floor). Antiseizure medication treatment occurred pre-pocEEG in 93 patients (59%) and post-pocEEG in 88 patients (56%). By reviewing the relationship between pocEEG monitoring and antiseizure medication management, we found a significant association between pocEEG findings and changes in management (P < 0.001). Treatment escalation occurred more frequently in patients with epileptiform activity (seizures or highly epileptiform patterns, 52%) than patients with non-epileptiform activity (normal or slow, 25%, P < 0.001), and avoidance of treatment escalation occurred more frequently in patients with normal or slow activity (27%) than patients with seizures or highly epileptiform patterns (2%, P < 0.001).

Conclusion

Our study, the largest to date describing the real-world use of pocEEG in emergency medicine, found that rapid EEG acquisition in the ED was feasible in a community hospital and significantly affected the management of suspected non-convulsive seizures.

Convulsive Status Epilepticus in a Cohort of Patients from a Peruvian Academic Hospital

BACKGROUND AND PURPOSE

Status epilepticus is a neurologic emergency whose epidemiology, etiology and management are scarcely known in developing countries. Our objective was to describe the demographic and clinical features as well as the management of generalized convulsive status epilepticus (GCSE) in adult patients admitted to the emergency department of an academic hospital in Peru, between March 2019 and March 2020.

METHODS

Observational study of a prospective cohort in which patients were assessed by the emergency and neurology department on the first day of hospitalization, at discharge and at 30 days post-discharge in a follow-up visit. Relevant demographics and clinical data were collected. After being encoded and sorted, univariate statistical analysis was carried out.

RESULTS

Of the sample of 59 patients, 62.7% were males, 57.6% were unemployed, 89.8% did not finish high school, and 55.9% had intermittent GCSE with no seizure at arrival. The total calculated median times were: 60 minutes from GCSE onset to hospital arrival, 110 minutes from GCSE onset to 1st line therapy, and 7 minutes from hospital arrival to 1st line therapy. The most frequently used antiepileptic drugs were one dose of benzodiazepine (41.7%), phenytoin (76.9%), and additional doses of benzodiazepines (60%) for 1st, 2nd, and 3rd line therapies, respectively. The most frequent etiologies were antiepileptic drug suspension (27.1%), undetermined (25.4%) and acute stroke (11.8%). 62.71% had 0-2 modified Rankin score at discharge.

CONCLUSIONS

In this cohort of patients, GCSE was mainly intermittent. Management times differed from the guidelines' recommendations.

A reappraisal of the value of video-EEG recording in the emergency department

Introduction: Some neurologic conditions that can quickly and with low costs be recognized, classified and treated thanks to the availability of an EEG recording in an emergency setting. However, although considered a cheap, not invasive, highly accurate diagnostic investigation, still today, an EEG recording in emergency, in real time during the event paroxysmal ictal phase, is not yet been become a routine.Areas covered: This review will cover the role and utility of EEG recording in the emergency setting, both in emergency department and intensive care unit, in adult and pediatric age, in people admitted for status epilepticus (convulsive or non-convulsive), paroxysmal non-epileptic events, or other conditions/diseases presenting with mental status changes.Expert opinion: The prompt recognition of some specific EEG-patterns can permit an immediate and appropriate therapeutic choice with the resolution of dramatic clinical pictures, which, if not recognized, sometimes could result in severe prognostic events with high mortality or neuropsychiatric disability. It is important in the next future, to improve the availability of these EEG digital continuous monitoring, which should be widely used in emergency settings, developing moreover tools and techniques permitting also review, analysis and EEG-reporting by experts who can work away from the hospital.

The electroclinical spectrum, etiologies, treatment and outcome of nonconvulsive status epilepticus in the elderly

BACKGROUND

Nonconvulsive status epilepticus (NCSE) in the elderly is particularly difficult to diagnose, mainly due to subtle clinical manifestations and associated comorbidities. The recently validated electroencephalography (EEG) diagnostic criteria for NCSE and the proposed operational classification of status epilepticus provide tools that can allow an earlier diagnosis and better management of NCSE in this age group, possibly contributing to reduce its high mortality.

MATERIAL AND METHODS

we used these tools to identify and characterize a cohort of elderly (>60year-old) patients admitted at our institution in a 3-year period; the video-EEG and clinical files of the patients fulfilling EEG diagnostic criteria for NCSE were reviewed, being in this study described their electroclinical spectrum, etiologies, treatment, inhospital mortality, and status epilepticus severity score (STESS).

RESULTS

Fourty patients (23 women; mean age 76.6years) were identified. Although dyscognitive NCSE associated with >2.5Hz of epileptiform discharges (ED) was the most frequent electroclinical phenotype, this was quite heterogeneous, ranging from patients with aura continua to patients in coma, associated with frequent ED or rhythmic slow activities. Acute symptomatic (45%) and multifactorial (27.5%) etiologies were the most common, and associated with the worst prognosis. There was a trend to use newer antiepileptic drugs in the early steps of NCSE treatment. The inhospital mortality was high (22.5%) and predicted by STESS scores ≥3.

CONCLUSION

In the elderly, NCSE has heterogeneous electroclinical phenotypes and etiologies. In spite of the treatment limitations conditioned by the comorbidities, more aggressive treatments could be justified to reduce mortality in patients with high STESS scores.

Can patients with non-convulsive seizure be identified in the emergency department?

BACKGROUND

Non-convulsive seizure (NCS) is an underdiagnosed, potentially treatable emergency with significant mortality and morbidity. The objective of this study is to examine the characteristics of patients with NCS presenting with altered mental status (AMS) and diagnosed with electroencephalography (EEG), to identify the factors that could increase the pre-test probability of NCS.

METHODS

Retrospective study using the data collected prospectively. Inclusion criteria: patients older than 13 years with AMS. Exclusion criteria: (1) immediately correctable AMS (e.g., hypoglycemia, opiod overdose); (2) inability to undergo EEG; (3) hemodynamic instability. Outcomes compared between NCS and non-NCS cases: vital signs, lactate level, gender, witnessed seizure, use of anticonvulsive in the field or in the ED, history of seizure or stroke, head injury, abnormal neurological finding and new abnormal findings on head CT. Data presented as medians and quartiles for categorical and percentages with 95%CI for continuous variables. Univariate analyses were performed with Man-Whitney U and Fisher's Exact tests. A multivariate analysis model was used to test the predictive value of clinical variables in identifying NCS.

RESULTS

From 332 patients (median age 66 years, quartiles 50-78), 16 were diagnosed with NCS (5%, 95%CI 3%-8%). Only age was significantly different between the NCS vs. non-NCS groups in both univariate (P=0.032) and multivariate analyses (P=0.016).

CONCLUSION

Other than age, no other clinically useful variable could identify patients at high risk of NCS. ED physicians should have a high suspicion for NCS and should order EEG for these patients more liberally.

Trend figures assist with untrained emergency electroencephalogram interpretation

OBJECTIVE

Acute electroencephalogram (EEG) findings are important for diagnosing emergency patients with suspected neurological disorders, but they can be difficult for untrained medical staff to interpret. In this research, we will develop an emergency EEG trend figure that we hypothesize will be more easily understood by untrained staff compared with the raw original traces.

METHODS

For each of several EEG patterns (wakefulness, sleep, seizure activity, and encephalopathy), trend figures incorporating information on both amplitude and frequency were built. The accuracy of untrained reviewers' interpretation was compared with that of the raw EEG trace interpretation.

RESULTS

The rate of correct answers was significantly higher in response to the EEG trend figures than to the raw traces showing wakefulness, sleep, and encephalopathy, but there was no difference when seizure activity patterns were viewed. The rates of misjudging normal or abnormal findings were significantly lower with the trend figures in the wakefulness pattern; in the other patterns, misjudgments were equally low for the trend figures and the raw traces.

CONCLUSION

EEG trend figures improved the accuracy with which untrained medical staff interpreted emergency EEGs. Emergency EEG figures that can be understood intuitively with minimal training might improve the accuracy of emergency EEG interpretation. However, additional studies are required to confirm these results because there may be many types of clinical EEGs that are difficult to interpret.

Diagnosis of reversible causes of coma

Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.

Electroencephalography findings in patients presenting to the ED for evaluation of seizures

BACKGROUND

Status epilepticus is a life-threatening, time-sensitive emergency. Acquiring an electroencephalogram (EEG) in the emergency department (ED) could impact therapeutic and disposition decisions for patients with suspected status epilepticus.

OBJECTIVES

The objective of this study is to estimate the proportion of EEGs diagnostic for seizures in patients presenting to an ED with a complaint of seizures.

METHODS

This retrospective chart review included adults presenting to the ED of an urban, academic, tertiary care hospital with suspected seizures or status epilepticus, who received an EEG within 24 hours of hospital admission. Data abstraction was performed by a single, trained, nonblinded abstractor. Seizures were defined as an epileptologist's diagnosis of either seizures or status epilepticus on EEG. The proportion of patients with seizures is given with confidence interval95 (CI95).

RESULTS

Of 120 included patients, 67 (56%) had a history of epilepsy. Mean age was 52 years (SD, 16), 58% were White, and 61% were male. Within 24 hours, 3% had an EEG diagnostic for seizures. Electroencephalogram was obtained in the ED in 32 (27%) of 120 (CI95, 19%-35%), and 2 (6%) of 32 (CI95, 1%-19%) had seizures. Electroencephalogram was performed inpatient for 88 (73%) of 120 (CI95, 65%-81%), and 2 (2%) of 88 (CI95, 0.5%-7.1%) had seizures.

CONCLUSION

Only 3% of ED patients with suspected seizures or status epilepticus had EEG confirmation of seizures within 24 hours. Early EEG acquisition in the ED may identify a group of patients amenable to ED observation and subsequent discharge from the hospital.

Novel wireless electroencephalography system with a minimal preparation time for use in emergencies and prehospital care

Background

Although clinical applications such as emergency medicine and prehospital care could benefit from a fast-mounting electroencephalography (EEG) recording system, the lack of specifically designed equipment restricts the use of EEG in these environments.

Methods

This paper describes the design and testing of a six-channel emergency EEG (emEEG) system with a rapid preparation time intended for use in emergency medicine and prehospital care. The novel system comprises a quick-application cap, a device for recording and transmitting the EEG wirelessly to a computer, and custom software for displaying and streaming the data in real-time to a hospital. Bench testing was conducted, as well as healthy volunteer and patient measurements in three different environments: a hospital EEG laboratory, an intensive care unit, and an ambulance. The EEG data was evaluated by two experienced clinical neurophysiologists and compared with recordings from a commercial system.

Results

The bench tests demonstrated that the emEEG system's performance is comparable to that of a commercial system while the healthy volunteer and patient measurements confirmed that the system can be applied quickly and that it records quality EEG data in a variety of environments. Furthermore, the recorded data was judged to be of diagnostic quality by two experienced clinical neurophysiologists.

Conclusions

In the future, the emEEG system may be used to record high-quality EEG data in emergency medicine and during ambulance transportation. Its use could lead to a faster diagnostic, a more accurate treatment, and a shorter recovery time for patients with neurological brain disorders.

Technical and clinical analysis of microEEG: a miniature wireless EEG device designed to record high-quality EEG in the emergency department

BACKGROUND

We describe and characterize the performance of microEEG compared to that of a commercially available and widely used clinical EEG machine. microEEG is a portable, battery-operated, wireless EEG device, developed by Bio-Signal Group to overcome the obstacles to routine use of EEG in emergency departments (EDs).

METHODS

The microEEG was used to obtain EEGs from healthy volunteers in the EEG laboratory and ED. The standard system was used to obtain EEGs from healthy volunteers in the EEG laboratory, and studies recorded from patients in the ED or ICU were also used for comparison. In one experiment, a signal splitter was used to record simultaneous microEEG and standard EEG from the same electrodes.

RESULTS

EEG signal analysis techniques indicated good agreement between microEEG and the standard system in 66 EEGs recorded in the EEG laboratory and the ED. In the simultaneous recording the microEEG and standard system signals differed only in a smaller amount of 60 Hz noise in the microEEG signal. In a blinded review by a board-certified clinical neurophysiologist, differences in technical quality or interpretability were insignificant between standard recordings in the EEG laboratory and microEEG recordings from standard or electrode cap electrodes in the ED or EEG laboratory. The microEEG data recording characteristics such as analog-to-digital conversion resolution (16 bits), input impedance (>100MΩ), and common-mode rejection ratio (85 dB) are similar to those of commercially available systems, although the microEEG is many times smaller (88 g and 9.4 × 4.4 × 3.8 cm).

CONCLUSIONS

Our results suggest that the technical qualities of microEEG are non-inferior to a standard commercially available EEG recording device. EEG in the ED is an unmet medical need due to space and time constraints, high levels of ambient electrical noise, and the cost of 24/7 EEG technologist availability. This study suggests that using microEEG with an electrode cap that can be applied easily and quickly can surmount these obstacles without compromising technical quality.

Diagnostic work-up and therapeutic options in management of pediatric status epilepticus

BACKGROUND

Status epilepticus (SE) is a life-threatening neurologic disorder comprising prolonged and unremitting crisis, and two or more series of seizures without complete intercritical recovery.

DATA SOURCES

We reviewed the literature through a Pubmed/Medline research using key words including status epilepticus, antiepileptic drugs and children, in order to revise and compare international/national protocols and to examine pediatric guidelines in SE management.

RESULTS

Neurologic impairment and SE etiology seem to be the most independent risks for mortality. A deep semiologic evaluation is essential to addressing diagnostic work-up. Ematochemical parameters, plasma levels of antiepileptic drugs and clinically oriented toxic/metabolic screening should be mandatory for investigating both causes and effects of SE. Electroencephalography is clearly helpful to characterize focal from generalized SE and to distinguish epileptic events from pseudoseizures, and it is deal to find nonconvulsive SE. Neuroimaging techniques could detect epileptogenic lesions (such as cortical malformations, tumors, demyelinating disorders or strokes) but are common in practice to find negative or controversial results. Pharmacologic management can be essentially arranged in three stages: benzodiazepines for early SE (lasting less than 30 minutes), phenytoin/fosphenytoin, phenobarbital, valproate, levetiracetam or lacosamide for established SE (30-90 minutes), and anesthetics for refractory SE (more than 90 minutes).

CONCLUSIONS

Status epilepticus is the most common neurologic emergency in childhood. A systematic diagnostic work-up and a three steps based therapeutic approach is required at this age.