The essence of the first 2.5 h in the treatment of generalized convulsive status epilepticus

Purpose: This study was designed to find realistic cut-offs of the delays predicting outcome after generalized convulsive status epilepticus (GCSE) and serving protocol streamlining of GCSE patients. Method: This retrospective study includes all consecutive adult (>16 years) patients (N = 70) diagnosed with GCSE in Helsinki University Central Hospital emergency department over 2 years. We defined ten specific delay parameters in the management of GCSE and determined functional outcome and mortality at hospital discharge. Functional outcome was assessed with Glasgow Outcome Scale (GOS1-3 for poor outcome, GOS > 3 for good outcome) and also defined as condition relative to baseline (worse-than baseline vs. baseline). Univariate and multivariate regression models were used to analyze the relations between delays and outcome. Delay cut-offs predicting outcome were determined using ROC-Curves. Results: In univariate analysis long onset-to-tertiary-hospital time (p = 0.034) was a significant risk factor for worse-than-baseline condition. Long delays in onset-to-diagnosis (p = 0.032), onset-to-second-stage medication (p = 0.023), onset-to-consciousness (p = 0.027) and long total-anesthesia-time (0 = 0.043) were risk factors for low GOS score (1-3). Short delay in onset-to-initial-treatment (p = 0.047), long onset-to-anesthesia (p = 0.003) and onset-to-consciousness (p = 0.008) times were risk factors for in hospital mortality. Multivariate analysis showed no significant factors. Cut-offs for increased risk of poor outcome were onset-to-diagnosis 2.4 h (p = 0.011), onset-to-second stage-medication 2.5 h (p = 0.001), onset-to-consciousness 41.5 h (p = 0.009) times and total-anesthesia time 45.5 h (p = 0.003). The delay over 2.1 h in onset-to-tertiary-hospital time increased the risk of worse than-baseline condition (p = 0.028). Conclusions: GCSE treatment is a dynamic process, where every delay component needs to be optimized. We suggest that GCSE patients should be handled with high priority and transported directly to hospital ED with neurological expertise. Critical steps in the treatment, such as diagnosing GCSE and starting progressive antiepileptic medication on stages 1 through 3, if needed, should be accomplished within 2.5 h. (C) 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.Peer reviewe

Emergency computed tomography in patients with first seizure

Purpose: To determine the frequency of emergent imaging findings on head computed tomography (CT) in an adult population of first seizure (FS) patients presenting to an emergency department (ED); and to search for associations between clinical features and emergent imaging findings among these patients. Methods: For this retrospective registry-based study, adult FS patients presenting to Helsinki University Hospital ED in 2006 were identified based on ICD-10 diagnosis. Clinical parameters were extracted from patient records. A neuroradiologist blinded to clinical information reviewed the CT scans for emergent imaging findings prompting changes in acute treatment, predefined as intracranial haemorrhage, acute ischemia, central nervous system infection, mass effect, midline shift, obstructive hydrocephalus and/or brain oedema. Results: 449 FS patients were identified, of which 416 (93%) had undergone emergency CT imaging. Of these, 49 (12%) had emergent imaging findings on non -contrast CT. Logistic regression suggested that headache (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.30-10.12), focal motor sign in the ED (OR 3.23, 95% CI 1.58-6.62), history of malignancy (OR 3.05, 95% CI 1.17-7.92), and altered mental state in the ED (OR 2.27, 95% CI 1.15-4.49) were associated with emergent imaging findings on NCCT. Presence of at least one of these factors had 84% sensitivity for emergent imaging findings. Conclusion: In FS patients, clinical information can be used to guide imaging decisions in the ED. However, if emergency imaging is not performed, urgent outpatient imaging and pre-imaging follow up should be secured. (C) 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.Peer reviewe