Improving Throughput, Mythbusting, Neurology, Twelve Trials of Christmas!

Day Two of Christmas – ‘Lytes off for Seizures?

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the second of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not.  All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

The ACEP clinical policy for seizures states to check electrolytes in new onset seizures, in patients with status epilepticus, and in those who are not back to baseline. They do not comment on patients with recurrent seizures who are back to baseline and do not have a compelling story (ie, fever, have not felt well recently, possible withdrawal, etc). Infrequently, if ever, have I seen a patient with clinically relevant hyponatremia that looked and felt well, let alone a patient with a hyponatremia-induced seizure that went back to their baseline and felt and looked fine. I have, however, frequently and instinctively ordered electrolytes “just to check” in a patient with a known seizure disorder with a normal exam and unconcerning history. Sometimes these patients wait well over an hour or two for labs to be drawn and resulted. I would love to see a multicenter retrospective study that looks at the rate of electrolyte abnormalities for which a patient with a known seizure disorder with a recurrent seizure required hospitalization due to said electrolyte disturbances. This could save a significant amount of time and resources likely without significant detriment to the patient. However, there is something about being able to document that you observed the patient for several hours without recurrence or a decline in their status. Then again, this could easily become a secondary outcome in the study I’d love to see (& do!) – is there a recurrence rate over a 1-2 hour observation period? Is there a 24 hour bounceback rate if an electrolyte panel is not drawn? How about outcomes at 1 month? Shockingly, there is scant, if any, literature on the need for labs to be drawn from a patient with a known seizure disorder having a breakthrough seizure.  I really think we could be turning off the ‘lytes for these patients if they are back at baseline and look & feel well.

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