Neuro / Critical Care II (May 2017)
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
11 comments
Jagoda et al.
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The main reason Jordan and I wanted to review this article is to standardize practice with first time seizure patients, as there seems to be a lot of variability in whether to consult neuro for these patients.
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For straight forward cases of patients who return to their baseline with normal neuro exam, in my practice, head imaging (CT) in the ED, or arranging for outpt MRI, and some blood work is usually enough (though yield of blood work can be argued), and pregnancy test.
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The whole point of neuro consult is to start AED’s. The the guidelines are clear that the benefits do not outweigh the risks for starting AED’s for a single first time seizure with neg workup. So why consult neuro?
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Perhaps a quick call to ask them to arrange outpt f/u and outpt imaging and/or EEG is enough.
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See latest ACEP clinical guidelines:
https://www.acep.org/MobileArticle.aspx?id=48428&coll_id=618&parentid=
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Just make sure you tell them not to drive. It’s the law!
Granata et al.
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Nothing we didn’t already know as our practice is consistent with the authors recommendations.
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Keep in mind they retrospectively looked at all their intoxicated patients, most of which probably didn’t have any signs of trauma. Sober and reassess is the way to go.
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Signs of head trauma still warrants much higher level of concern and lower threshold to scan than those without.
Granata et al.
I actually presented this article at conference in November for journal club. It’s definitely a flawed study. Strengths include that it is a commonly-encountered clinical scenario. However, there are a lot of limitations. One big limitation for me is that patients were categorized by ICD9 codes for alcohol intoxication. However, many intoxicated patients may not be coded as such and one patient was coded as intoxicated but alcohol level was zero. Also one could argue that the article’s definition of neurosurgical intervention is flawed. Main outcome is need for neurosurgical intervention. Does this article change my practice? No.
Jagoda et al.
1. How has reading the article changed your practice? It hasn’t. One comment: I like how the article advocates for reducing the use of labs, and I think that in general labs are ordered too often in emergency medicine. However, I disagree with the article that hyponatremia can easily be identified by history and exam. This statement seems divorced from the realities of emergency medicine practice, especially in a busy ED.
2. What information had you believed in previously that were debunked by reading this article? N/A
3. What new information did you learn from reading this article? 45% of patients with first time seizure have no cause of seizure identified.
4. What are current areas of uncertainty on this topic that can be potential areas for research? Disposition for well-appearing patients with first time seizure and no co-morbidities.
Jagoda et al
1. Not a whole lot. I recall a teaching rounds Chris did for us on a slow morning about first time seizures. His takeaway was pretty much the same as this. I’ve heard TSH mentioned for first time seizure workup, but I’ll probably not do that routinely at this point. As Alex said above, CT for first time in ED, or outpatient MRI, both are reasonable.
2. As above, I’ll stop ordering TSH here unless clinically indicated.
3. The two most common lab abnormalities in new onset seizures are hypoglycemia and hyponatremia. Could have guessed it, but good to see it written,
4. I’d be interested to see a larger study about the need for any emergent CT at all in first time seizures that return to baseline neurological status. Seems like these could all be done as an outpatient. Obviously scan the abnormal cases and have a low threshold to do so, but with normal lytes in healthy individuals who are upset about having to wait for CT to open up, why not send them home with follow up?
Granata et al.
What are some strengths of the study? it’s a worthwhile question to address, the numbers are large because it’s such a common ED presentation
What are the limitations? obviously this is a difficult patient population to track, so this study is limited by a lack of follow-up. these patients who were discharged without a CT scan could theoretically have a slow subdural that manifested at a different ED. Despite having ~6000 patients, only (13) 0.3% of all patients had acute intracranial findings. Because the number of events is so low, there is not sufficient data to comment on whether “delaying” CT scan is appropriate, rather scanning at all would be the more appropriate study endpoint. There are other limitations as mentioned in the other comments, like the neurosurgical emergency that was not treated emergently.
What are the main outcomes of the study? Intracranial findings is very rare in intoxicated patients without signs of trauma above the clavicle. You can safely defer CT scan until etoh is metabolized to get a history and exam.
Does reading this article change your practice? If so, how? No.
Jagoda et al.
How has reading the article changed your practice? reinforced that neuroimaging in ED is very high yield, one study cited 85/247 first time seizures who got CT scans showed stroke/tumor (20% with nonfocal exam with CT abnormalities). Sodium, glucose, and pregnancy test should be the only labs sent
What information had you believed in previously that were debunked by reading this article? not much.
What new information did you learn from reading this article? 1-year recurrence risk of 65% in those with structural lesions or focal seizures
What are current areas of uncertainty on this topic that can be potential areas for research? Neuroimaging in the ED for this population clearly impacts diagnostic yield, but does it change patient outcomes such as recurrence or seizure or other morbidity? Especially given reports that AEDs may not decrease recurrence in all populations.
#firsttimeseizure
Change in practice? Call me conservative but probably just won’t’ get a glucose/Na/pregnancy as suggested…never mind the fact the pt might may come to trauma 1 and get everything under the sun. The article is also a good reminder not to anchor etoh pts as having w/d sz given that the authors cite a study that close to 60% of etoh pt’s with first time sz had an abnormal head CT. Also will be making sure to check if the pt’s pregnant since I likely won’t be able to tell if she’s 20 weeks pregnant or not otherwise.
Debunked info? Less than 10% of first time sz are 2/2 metabolic or tox – I thought it was more. ACEP and AAN aren’t big fans extensive metabolic testing for first time sz.
New Info? Half of first time sz pts have no etiology found. Up to 60% of etoh d/o pts with sz have abnormal CTH. 65% 1 year recurrence rate if you have a CT with a structural lesion.
Research? More research on short term (ie, 24 hours) sz recurrence. Will my pretty healthy pt who seized and had an unremarkable ED w/u sz again after ED discharge? Also, article doesn’t touch on utility (or not) of lactate/creatinine kinase/prolactin – would be good to know when these are recommended.
#EtohandCTH
– Strengths? It tries to answer a commonly scene scenario in the ED.
– Limitations? Retrospective. Not powered enough. No follow up. Only 2 EDs (ie, not generalizable)
– Outcomes? Routine CTH of etoh intoxicated pts has low clinical value
– Change practice? Not really. Although I will say that I make sure to assess for trauma in etoh/drug intoxicated pts after learning the hard way. I think it was my 2nd month intern year when an etoh intoxicated pt was moaning and not willing to take off his sweater for an exam. I came back to Ron Medzon describing a likely “sober reeeval.” Ron comes back to me in 10 minutes and says very softly in a very Medzon-esque manner, “You might want to check his pupils.” Sure enough, I go back and one pupil is blown. Guy had a major head bleed. Learning point – make sure to check the pupils.
Defer CT in intoxicated patients
1. The main strength of this study is that it seeks to answer a question that we are faced with multiple times a day – to CT or not to CT? And unlike most studies which exclude vulnerable populations, this study targets a vulnerable population that we care for all of the time.
2. Many of the limitations that the authors discuss are not actually limitations in my opinion. I do think that a lack of follow up for patients discharged without CT is a possible limitation, but one can assume that their mental status improved significantly and that they were acting normally before discharge. I also like that their criteria captured patients who were primarily coded as “intoxication”, as this is the population that poses the greatest dilemma.
3. Deferring CT imaging in alcohol intoxicated patients in favor of “sober reassess” is a safe practice.
4. Not really – I certainly don’t order head CTs on every intoxicated patient that I see. I do if there is a clinical concern for trauma, but the authors do discuss how patients who were primarily coded as head trauma were not captured in this study, which I think is appropriate. Also, another takeaway from this article is if you suspect EtOH but they blow 0, get that head CT! (not practice changing either, but a good reminder)
First time seizure
1. I guess I will be more likely to discharge patients with first time seizure if my workup has not revealed a cause and they are back to baseline (and they are low risk).
2. I thought it was interesting that the recommendation states “there are insufficient data to support or refute routine recommendation of laboratory tests such as glucose, blood counts, and electrolyte panels”. I have always done lab tests (and not EEGs)
3. I learned about gestational epilepsy, and how 14 of 59 pregnant patients with first time seizure were found to have gestational epilepsy.
4. There are lots of areas of uncertainty, such as why some studies found increased risk of seizure recurrence if first time seizure patients are started on antiepileptics. For these first time seizures with negative workup – why did they even seize in the first place?