Evaluation and management of patients with seizures in the emergency department: a one-year analysis

Abstract

Introduction. Transient loss of consciousness (TLoC) encompasses symptoms caused by either syncope, seizures or psycogenic disorders which are all frequent in the emergency department (ED). The study aims to determine the prevalences of causes of TLoC in the ED, analyse the characteristics of patients with seizures or established epilepsy in particular and estimate the level of evaluation and management they receive in respect to available international guidelines. Materials and methods. The data was cross-sectional and was retrieved from the local database of Vilnius University Hospital Santaros Klinikos from January 1st to December 31st 2016. Adult patients with diagnoses (coded in the International Statistical Classification of Diseases and Related Health Problems, ICD-10-AM) of syncope (R55), epilepsy (G40) or other and unspecified convulsions (R56.8) assigned either by the emergency medical services or the ED staff were involved in the study (315 cases). The data was analysed with Microsoft Excel v16.0 and IBM SPSS Statistics v20, two-sided Fisher’s exact and Mann-Whitney U tests were employed (p<0.05). Results. As diagnoses provided by emergency services and the ED staff were conflicting, only the latter were used for the assortment. The majority of patients brought to the ED with TLoC (average age 53.5±20.8) had syncope or collapse (134, 42.5%), 54 (17.1%) had epilepsy, and 32 (10.2%) had other and unspecified convulsions, which encompass mostly new-onset seizures. The mean age of patients with established epilepsy was 47.6±15.7 and significantly (p=0.014) lower than due to other causes. Male gender predominated in all-cause seizures (odds ratio OR=1.7; 95% confidence interval CI=1.0-2.9, p=0.042). Laboratory blood tests were commonly used for all patients, but patients with epilepsy received computed tomography (CT) scans and were hospitalized more often than other patients (p<0.001, p=0.002, respectively). Both an electrocardiography (ECG) and troponin blood levels (both often received after syncope and collapse) were evaluated less frequently in these cases, however (p<0.001). Focal seizures (32, 59.3%) and alcohol-related metabolic seizures (8, 14.8%) were most common with epilepsy; unknown or unspecified (22, 68.8%) and generalized (6, 18.8%) – with new-onset seizures. For outpatients with epilepsy, alcohol abstinence (16, 44.4%) and everyday (lifestyle, work etc.) recommendations (13, 36.1%) were most common, treatment was often modified (14, 38.9%). Outpatients with seizures but no diagnosed epilepsy were most often advised to consult a neurologist, receive an electroencephalography (EEG) (19, 76.0% and 11, 44.0%, respectively), and abstain from alcohol ( 11, 44.0%), but treatment was almost never prescribed. Conclusions. Syncope and collapse caused most cases of TLoC, followed by established epilepsy and new-onset seizures. Patients with epilepsy were younger than in other cases and in assessing all presentations with seizures, male gender predominated. The evaluative practices and care complied with selected international guidelines in most cases, except for some approaches related to neuroimaging and information deliverance.