Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2)

Abstract

Objective: To determine the clinical characteristics, management and outcomes of patients taken to hospital by emergency ambulance after a suspected seizure.

Design: Quantitative cross-sectional retrospective study of a consecutive series of patients.

Setting: An acute hospital trust in a large city in England.

Participants: In 2012-2013, the regions' ambulance service managed 605 481 emergency incidents, 74 141/605 481 originated from Sheffield (a large city in the region), 2121/74 141 (2.9%) were suspected seizures and 178/2121 occurred in May 2012. We undertook detailed analysis of the medical records of the 91/178 patients who were transported to the city's acute hospital. After undertaking a retrospective review of the medical records, the best available aetiological explanation for the seizures was determined.

Results: The best available aetiological explanation for 74.7% (68/91) of the incidents was an epileptic seizure, 11.0% (10/91) were psychogenic non-epileptic seizures and 9.9% (9/91) were cardiogenic events. The epileptic seizures fall into the following four categories: first epileptic seizure (13.2%, 12/91), epileptic seizure with a historical diagnosis of epilepsy (30.8%, 28/91), recurrent epileptic seizures without a historical diagnosis of epilepsy (20.9%, 19/91) and acute symptomatic seizures (9.9%, 9/91). Of those with seizures (excluding cardiogenic events), 2.4% (2/82) of patients were seizing on arrival in the Emergency Department (ED), 19.5% (16/82) were postictal and 69.5% (57/82) were alert. 63.4% (52/82) were discharged at the end of their ED attendance and 36.5% (19/52) of these had no referral or follow-up.

Conclusions: Most suspected seizures are epileptic seizures but this is a diagnostically heterogeneous group. Only a small minority of patients require emergency medical care but most are transported to hospital. Few patients receive expert review and many are discharged home without referral to a specialist leaving them at risk of further seizures and the associated morbidity, mortality and health services costs of poorly controlled epilepsy.

Keywords: Epilepsy; Neurology.

Figure 1

Flow chart to illustrate the care pathway and exclusions throughout the EPIC study (EPIC1 and EPIC2). The EPIC1 exclusions were as follows: missing/inadequate data (18/178) and miscellaneous, for example, hoax call (6/178). The non-seizure diagnoses in EPIC1 were as follows: syncope, intoxicated/passed out, tremor/spasm, fall, rigours, twitching, panic attack, anxiety/hyperventilation, abnormal behaviour and social/miscellaneous/inappropriate. The non-seizure diagnoses in EPIC2 were 5/8 vasovagal, 1/8 syncope, 1/8 complete heart block and 1/8 collapse. EPIC, Epilepsy Pre-Hospital Interventions and Care.

Figure 2

Physiological parameters and the Sheffield Early Warning Score (SHEWS) for each of the patients on arrival in the Emergency Department. SHEWS score: 1 = increase frequency of observations and inform nurse, 2 = hourly observations and consider medical review, 3 = immediate medical review. No patients had a SHEWS score recorded that was higher than 1. Normal ranges: HR (60–100 bpm), RR (14–18 breaths per minute), systolic BP (100–140 mm Hg), blood glucose (3.5–11.1 mmol/L), temperature (36.5°C–37.5°C), O₂ sat (<94%) and GCS (15/15). BP, blood pressure; GCS, Glasgow Coma Score; O₂ sats, oxygen saturations; HR, heart rate; RR, respiratory rate.

Figure 3

Best available aetiological explanation for the index event. Acute symptomatic causes were: alcohol withdrawal, head injury, hypoglycaemia and transient ischaemic attack. The cardiogenic events were vasovagal episode, syncope, complete heart block and collapse.

Figure 4A–D

Data from EPIC1 and EPIC2 to illustrate diagnoses, exclusions and missing data at each stage in the care pathway. Pre-Hospital Diagnoses(A). In Sheffield May 2012, there were 178 suspected seizures for which 999 was called. A total of 24/178 were excluded and 22/178 were not seizures leaving 132/178 suspected seizure incidents that were studied in detail in EPIC1. Exclusions: missing/inadequate data (18/178, 10.1%) and miscellaneous, for example, hoax call (6/178, 3.4%). The clinical impression of the ambulance clinicians was that there was no evidence of seizure activity in 22/178 (12.4%). Not seizure diagnoses: syncope (3), intoxicated/passed out (2), tremor/spasm (2), fall (2), rigours (2), twitching (1), panic attack (1), anxiety/hyperventilation (2), abnormal behaviour (1) and social/miscellaneous/inappropriate (6). Hospital Diagnoses (B–D). Best Available Diagnoses (B). The hospital notes of 91/132 were analysed in detail (98/132 were transported to hospital but 4/98 transported to an hospital outside Sheffield and 3/98 sets of notes were not available). The best available data for the aetiology of the 91 events is shown in B (this is based on data from all sources: ED notes, inpatient notes and epilepsy clinic notes). Aetiology of acute symptomatic seizures: alcohol withdrawal (6), head injury (1), hypoglycaemia (1) and transient ischaemic attack (1). Emergency Department Diagnoses (C). A total of 82/91 that were transported to ED at Sheffield Teaching Hospitals NHS Foundation Trust were suspected seizures. A total of 9/91 were given non-seizure diagnoses: vasovagal episode (6), syncope (1), complete heart block (1) and collapse (1). NB/An additional 1/91 suspected seizure was transported direct to an inpatient ward so 82/91 were diagnosed with suspected seizures. Inpatient Diagnoses (D). A total of 27/83 were admitted to an inpatient ward.