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

      Dickson, Jon M.; Dudhill, Hannah; Shewan, Jane; Mason, Suzanne; Grünewald, Richard A.; Reuber, Markus (2017-07)
      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 https://bmjopen.bmj.com/content/bmjopen/7/7/e015696.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2016-015696
    • Cross-sectional study of the prehospital management of adult patients with a suspected seizure (EPIC1)

      Dickson, Jon M.; Taylor, Louise H.; Shewan, Jane; Baldwin, Trevor; Grünewald, Richard A.; Reuber, Markus (2016-02)
      Objectives: Suspected seizures are a common reason for emergency calls to ambulance services. Prehospital management of these patients is an important element of good quality care. The aim of this study, conducted in a regional ambulance service in the UK, was to quantify the number of emergency telephone calls for suspected seizures in adults, the associated costs, and to describe the patients’ characteristics, their prehospital management and their immediate outcomes. Design: Quantitative cross-sectional study using routinely collected data and a detailed review of the clinical records of a consecutive series of adult patients (≥16 years). Setting: A regional ambulance service within the National Health Service in England. Participants: Cross-sectional data from all 605 481 adult emergency incidents managed by the ambulance service from 1 April 2012 to 31 March 2013. We selected a consecutive series of 178 individual incidents from May 2012 for more detailed analysis (132 after exclusions and removal of non-seizure cases). Results: Suspected seizures made up 3.3% of all emergency incidents. True medical emergencies were uncommon but 3.3% had partially occluded airways, 6.8% had ongoing seizure activity and 59.1% had clinical problems in addition to the seizure (29.1% involving injury). Emergency vehicles were dispatched for 97.2% of suspected seizures, the seizure had terminated on arrival in 93.2% of incidents, 75% of these patients were transported to hospital. The estimated emergency management cost per annum of suspected seizures in the English ambulance services is £45.2 million (€64.0 million, $68.6 million). Conclusions: Many patients with suspected seizures could potentially be treated more effectively and at lower cost by modifying ambulance call handling protocols. The development of innovative care pathways could give call handlers and paramedics alternatives to hospital transportation. Increased adoption of care plans could reduce 999 calls and could increase the rates of successful home or community treatment. https://bmjopen.bmj.com/content/bmjopen/6/2/e010573.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2015-010573
    • Palliative emergencies in the pre-hospital setting

      Parkinson, Martin (2014-10)
      Abstract published with permission. Objective: To provide a narrative on the most common palliative emergency situations that requires the attendance of a paramedic. This narrative looks specifically at pain, seizures and breathlessness, and critiques the underpinning evidence supporting their treatment and protocols. Discussion: Pain—the presence of pain in palliative care is highly prevalent with up to 70% of patients living in a permanent painful state. Clinician-led pain assessment has been shown to underestimate the patient’s pain by as much as 60–68% and none of the assessment tools used are fully inclusive. Further research is needed to formulate an assessment tool that recognises palliative pain as a progressive disorder requiring constant assessment. Seizures—Seizures occur as either a result of disease progression or as a side effect of medications. Studies have shown that intramuscular midazolam is more effective than intravenous lorazepam, which is itself more effective than intravenous diazepam. The ease of administration of intramuscular and buccal midazolam for out-of-hospital use should make midazolam the first-line treatment for palliative care patients that suffer from seizures. The implication for future paramedic practice highlighted from these studies is the need for more research in the treatment of palliative patients with seizures. Breathlessness—Cold facial stimulation has been shown to be very effective as a non-pharmacological treatment for breathlessness. Opioids help to relax the patient which aid in regulating breathing patterns although a consensus on the route of administration which provides the best possible effect is yet to be reached. The evidence base for the use of anxiolytics is weak and some studies have shown no beneficial effect to their use. Although anxiolytics are effective in reducing anxiety their effectiveness in helping breathlessness in palliative patients is questionable. Home oxygen should be adopted as a first line treatment according to experts working in end-of-life care, and treatment of oxygen should not be delayed by waiting for results of other trials for other treatments.
    • Pre-hospital care after a seizure: evidence base and United Kingdom management guidelines

      Osborne, Andrew; Taylor, Louise H.; Reuber, Markus; Grünewald, Richard A.; Parkinson, Martin; Dickson, Jon M. (2015-01)