Epilepsy and Status Epilepticus (2024)

December 2, 2024December 9, 2024 ~ iEM Education Project Team ~ Leave a comment

by Rand Redwan Al Sari & Imad Khojah

You have a new patient!

A 22-year-old woman is brought to the ER because of violent, jerky movements of her limbs that started 30 minutes ago. Her husband reports that the patient has a history of epilepsy. She is unresponsive. Her examination reveals tonic-clonic episodes and blood in her mouth. How would you manage this case? What are the initial steps you would take? What actions are needed to stop the seizure?

What do you need to know?

Epidemiology and Importance

Epilepsy is one of the most common neurological diseases that can present to the emergency department [1]. It affects about 50 million people around the world, with an incidence of approximately 50.4 to 81.7 per 100,000 per year [1]. Epilepsy refers to having a lower seizure threshold than normal due to genetic, pathological, or unknown causes [2]. It is characterized by recurrent unprovoked seizures that present with motor, sensory, autonomic, or cognitive function alterations [2]. Previously diagnosed patients can present to the ED with breakthrough seizures due to factors like changes in the anti-seizure regimen or noncompliance with medication [2]. Other factors like sleep deprivation, stress, and flashing lights can also precipitate breakthrough seizures [2].

Prolonged or repetitive uncontrollable seizures are termed status epilepticus [2,3]. This emergency requires prompt treatment to prevent neuronal injury, severe disability, coma, or death [3]. The overall case fatality rates can reach up to 15% [2].

Pathophysiology

Neurons are normally stabilized by a balance between excitatory and inhibitory neurotransmitters [2]. A disruption of this balance leads to abnormal electrical discharge [2]. This discharge can propagate to nearby areas in the brain, which is evident clinically by the stepwise spread of the seizure (known as Jacksonian March) [2, 4]. Loss of consciousness in some cases is explained by the widespread involvement of large areas of the brain [2]. Many drugs used to restore this balance work by enhancing inhibitory activity through targeting GABAA subtype receptors [2]. Prolongation of the seizure leads to sequestration of GABAA receptors and upregulation of excitatory receptors; therefore, patients become unresponsive to medication [2, 5]. This explains the importance of timely treatment through early seizure control to prevent morbidity and mortality in patients with status epilepticus [2,3].

Medical History

A common scenario presenting to the ER is a patient complaining of a seizure-like episode with a sudden loss of consciousness and motor activity involvement [6]. However, various other presentations of seizures and other differential diagnoses with similar complaints should not be neglected. If the patient presents with status epilepticus, timely management, depending on the seizure type, is urgently needed (see management) [2].

Through history and examination, distinguishing a seizure from other acute medical conditions is important. An accurate diagnosis has crucial, direct consequences for activity restriction and therapy planning. Paying attention to features, especially at the onset, can help in identifying the seizure type for therapeutic implications and facilitate communication between physicians. Semiology at onset is important to classify seizures as focal, focal with impaired awareness (complex seizures), generalized, or unknown [7]. Further classification divides motor and non-motor seizures based on the descriptive assessment of the first symptom, which can vary widely according to the area of the brain affected [2].

The main aim of history-taking is to identify seizures from other similar conditions, classify them, identify triggers of new seizures, and detect a cause for a decreased seizure threshold in a patient previously diagnosed with epilepsy [8].

It is important for any patient with seizures to consider critical causes such as eclampsia, toxic ingestion, hypoglycemia, electrolyte imbalance, and increased intracranial pressure [9]. Emergent diagnoses, such as infection, acute brain injury, and serious mimics of seizure activity, must be identified and treated as soon as possible [2].

Initial history approach to a patient with suspected seizure [2] is a systematic evaluation, starting with the assessment of whether the event is likely to be a seizure, followed by differentiation of first-time versus recurrent seizures, and identifying factors that may trigger or reduce seizure thresholds [10].

Algorithmic Approach in Seizure History [2]

Determining Likelihood of a Seizure

The process begins by evaluating whether the event could be a seizure. Key indicators include:

Aura: A subjective sensation preceding the seizure.
Abrupt onset: Sudden occurrence of the event.
Non-suppressible limb shaking: Movements that are not voluntary or suppressible.
Postictal state: A transient neurological state after the event, characterized by confusion or fatigue.
History of epilepsy: Previous diagnosis or known history can strongly support the likelihood.

If these features are absent, the clinician is prompted to consider alternative diagnoses, such as:

Syncope (fainting),
Stroke,
Complex migraine, or
Non-epileptic spells, which may mimic seizures but lack neurological underpinnings.

Differentiating First-Time Seizures

If the event is determined to likely be a seizure, the next step is assessing whether it is the patient’s first seizure. For first-time events, the focus shifts to identifying potential triggers, including:

Medications: Use of or withdrawal from drugs that may lower the seizure threshold.
Exposures: Environmental or toxicological factors.
Immunosuppression: Conditions that may predispose to infections affecting the brain.
History of head trauma: A common precipitant for seizures.
Pregnancy: Associated risks like eclampsia.

Characterization of the Seizure

If it is not a first-time seizure, further characterization of the event is essential. Key aspects include:

Onset: Understanding preceding events to identify immediate triggers and auras.
Duration: Length of the seizure episode.
Awareness: Assessing the patient’s level of consciousness during the seizure.
Automatisms: Involuntary, purposeless movements that occur during the seizure and can be observed by others.
Postictal state: The presence of transient neurological deficits following the seizure (absent in some types, such as absence seizures).

The clinician also verifies whether the current event is consistent with the patient’s previous seizure patterns.

Exploring Factors Reducing the Seizure Threshold

For patients with recurrent seizures, it is crucial to evaluate factors that might decrease the seizure threshold, including:

Non-compliance or changes to anti-seizure drug (ASD) regimens.
Illness or trauma: Physical or psychological stressors.
Drug or alcohol use: Acute intoxication or withdrawal.
Catamenial exacerbations: Hormonal influences in menstruating individuals.
Pregnancy: Increased risk of seizures due to physiological changes or complications.
Sleep deprivation: A well-documented precipitant of seizures.

This step ensures that modifiable triggers or exacerbating factors are identified and addressed.

Physical Examination

Physical examination is crucial for identifying etiologies and directing the management plan. During an active seizure, pay close attention to posture, motor activity, eye deviation, and nystagmus, observing asymmetries and focal findings [11]. Check if the clonic activity is suppressible by applying gentle pressure. Unlike insuppressible seizures, suppression suggests a different diagnosis, such as nonepileptic spells or movement disorders. Check for mydriasis in the eyes, which is commonly found during seizures, but its persistence afterward can indicate toxic exposure [2].

Vital signs should be measured after seizure activity has ceased. They are of high importance and may direct the physician to possible causes (e.g., fever suggests meningoencephalitis, tachycardia and hypertension suggest toxic sympathomimetic exposure, while hypertension and bradycardia can indicate herniation syndromes) [2].

Moreover, a general examination should aim to search for both findings and sequelae of the seizures. Physical findings such as nuchal rigidity, stigmata of substance abuse, and lymphadenopathy may be present. Potential sequelae of seizures should also be assessed [12]. Evaluation of soft tissue and skeletal trauma is important, as injuries are common. Check for head trauma, tongue injury, shoulder dislocation, bone fractures, or aspiration [2].

Finally, a complete neurological examination should be performed. Immediately following the seizure, hyperreflexia, focal motor deficit (Todd’s paralysis), and extensor plantar response (positive Babinski) can occur and are expected to generally resolve within an hour [13]. If Todd’s paralysis does not resolve quickly, it raises the suspicion of a focal structural deficit that caused the seizure (e.g., stroke). The persistence of altered consciousness or signs of ongoing subtle seizures, such as automatisms, abnormal eye movements, and facial myoclonus, suggests the persistence of the seizure and must not be missed (nonconvulsive seizures and status epilepticus) [2].

Alternative Diagnoses

Although no single clinical finding or diagnostic modality is 100% confirmatory of the diagnosis of seizures [14, 15], understanding the circumstances of the event and the factors surrounding it can help rule out or confirm diagnoses with similar presentations [2].

Findings that make the diagnosis of seizures more probable include postictal disorientation and amnesia, cyanosis during the event, lateral tongue biting, non-suppressible limb shaking, and dystonic posturing [2, 15].

If the patient experienced diaphoresis, palpitations, nausea, and vomiting before the seizure, it may suggest transient cerebral ischemia due to arrhythmias [2].

The presence of motor activity, commonly including a tonic extension of the trunk or myoclonic jerks of the extremities associated with bradycardia, raises the suspicion of convulsive syncope [16]. Once cerebral perfusion is restored, convulsions stop without any postictal period [2].

The diagnosis of migraine can sometimes be misleading due to the presence of a preceding aura that might be confused with nonconvulsive seizures (e.g., the positive visual phenomenon in occipital seizures) [17]. Unlike occipital seizures, migraines have a peak preceded by gradual evolution and followed by gradual resolution. Moreover, patients typically have a positive history of migraines with a similar presentation [2].

Nonepileptic spells or psychogenic seizures mimic status epilepticus in their presentation [18]. Due to the prolonged duration of the spells (five minutes or more, and sometimes exceeding 20 minutes), patients commonly receive high doses of benzodiazepines and need to be monitored for any respiratory compromise. Findings consistent with this diagnosis include a stop-and-go pattern of the convulsions, horizontal head shaking, forward pelvic thrusting, asynchronous bilateral convulsions with eyes closed, a short postictal period despite the long duration of spells, avoidance of noxious stimuli, and preserved recollection of events. Furthermore, laboratory testing lacks reactive leukocytosis and lactic acidosis, which are present in nearly all cases of prolonged generalized convulsive seizures or status epilepticus [2, 19].

Acing Diagnostic Testing

Due to the challenges of diagnosing a seizure, seeking diagnostic testing is of high value. Laboratory studies, radiology, and other special procedures frequently provide important elements in patient assessment [20]. Although some cases require extensive metabolic testing, it is not indicated for cases with an unremarkable history and normal examination findings. Serum glucose levels should be measured in all cases, as hypoglycemia is a common cause of provoked seizures [21]. It is also important to note that hypoglycemia could result from prolonged seizures. If correcting the glucose level does not stop a seizure, an alternate diagnosis should be evaluated. Lactic acid and creatinine kinase should also be measured in cases of prolonged seizures to assess for acute metabolic acidosis and rhabdomyolysis, respectively [22]. A low level of lactic acid during a prolonged convulsive episode makes a seizure less likely (nonepileptic convulsions) [2].

On the other hand, the presence of advanced age, comorbidities, abnormal examination findings, or an ill appearance demands comprehensive metabolic testing. Such testing includes serum glucose, creatinine kinase, lactic acid, electrolytes, complete blood count, urea nitrogen, creatinine, AST, ALT, anti-seizure drug levels, pregnancy tests, and drug-of-abuse screening. Checking for electrolyte derangements is important, as these can trigger seizures (e.g., hyponatremia, hypocalcemia, and hypomagnesemia) [23]. Patients with a low bicarbonate level should undergo blood gas analysis. An anion gap metabolic acidosis resulting from lactic acidosis is expected to decline within the first hour after the convulsive seizure stops unless another cause is present. Liver enzymes are tested to check for liver-mediated metabolic abnormalities that can impact therapeutic decisions [2].

Furthermore, patients on antiseizure medication should have their levels checked to confirm compliance. Some drugs are known to be epileptogenic, and it may be necessary to test their levels as well. Drug-of-abuse screening can also be considered in patients presenting with first-time seizures, despite the fact that such testing cannot prove causation or change outcomes [2, 24].

Urgent neuroimaging is indicated for most cases of a first-time seizure, whereas patients with epilepsy who have returned to baseline do not require one. Prompt neuroimaging and CT consideration in the ER is indicated for patients with coma, focal neurological deficits, immunocompromised states, advanced age, anticoagulation use, malignancy, previous intracranial hemorrhage, severe thunderclap headache, status epilepticus, neurocutaneous syndromes, or suspected trauma [25]. Computed tomography (CT) is widely available, but MRI and CT perfusion can provide additional information. If an infection is suspected, lumbar puncture is indicated [2].

Electroencephalography (EEG) is useful for diagnosing nonconvulsive seizures, epilepsy, nonepileptic spells, and status epilepticus [26]. EEG can guide therapy and monitor the treatment of refractory cases. Although it is not cost-effective, it is a high-yield modality for cases with an unclear diagnosis [2].

Lastly, ECG monitoring might benefit patients with preceding or ongoing cardiac symptoms. It can provide early clues in cases of drug toxicity and help understand the etiology of the seizure [2, 27].

Risk Stratification

The presentation and findings of a seizure case can provide clues as to whether this case has any red flags that demand urgent care. History and examination findings such as immunocompromisation, the presence of a thunderclap headache, sudden neurological deficit, status epilepticus presentation, head trauma, persistent altered consciousness, and concurrent infection can indicate a worse outcome [10]. Such patients require extensive investigations and prompt treatment to minimize morbidity and mortality due to the cause of the seizure or as a consequence of the seizures themselves [28]. Critical care for these patient groups is essential to reduce complications such as infection-related issues, irreversible intracranial structural disease, refractory status epilepticus, hemodynamic compromise, and death [2].

The risks of experiencing a secondary seizure following the current presentation may change the management plan to include secondary seizure prophylaxis. Risk stratification, weighing the chances of recurrence (higher in patients with previous brain insult, abnormal EEG, brain imaging abnormalities, and the presence of nocturnal seizures) against the risks of adverse effects from antiseizure medication, should be conducted in collaboration with a consulting neurologist [2].

Management

The initial priorities in managing unstable patients are to recognize and treat hypoxia, hypotension, and hypoglycemia, and to initiate pharmacologic treatment when needed [2, 28, 29].

Initial stabilization of patients with active seizures presenting to the ER includes the following [2, 28, 29]:

Assess airway, breathing, and circulation: Do not use nasopharyngeal airway devices during the seizure, as they can cause injury and increase the risk of aspiration.
Pulse oximetry.
Electrocardiogram (ECG).
Finger stick: If the glucose level is less than 60 mg/dL, administer IV dextrose.
Aspiration precaution: Place the patient in the lateral decubitus position.
Abortive treatment: Administer if the seizure lasts more than 5 minutes or in the case of hemodynamic compromise.

First-line therapy [2, 28, 29]

The first-line pharmacological therapies for managing epilepsy, include three benzodiazepine agents: diazepam, lorazepam, and midazolam. These agents are commonly used for their rapid onset and efficacy in controlling seizures, especially status epilepticus. The table includes critical details on dosing, frequency, maximum permissible dose, pregnancy category, and specific cautions.

Diazepam

Dose per kilogram: 0.15-0.2 mg/kg intravenously (IV).
Frequency: Administered every 5 minutes as needed.
Maximum Dose: Limited to 10 mg per individual dose and a cumulative total of 30 mg across all doses.
Pregnancy Category: D (indicating a potential risk to the fetus, but benefits may outweigh risks in life-threatening situations).
Cautions/Comments:
- Continuous monitoring of respiration is essential due to the risk of respiratory depression, a common side effect of benzodiazepines.

Lorazepam

Dose per kilogram: 0.1 mg/kg intravenously (IV).
Frequency: Administered every 5 minutes as necessary.
Maximum Dose: 4 mg per dose, with a cumulative maximum of 12 mg across all doses.
Pregnancy Category: D.
Cautions/Comments:
- Similar to diazepam, respiratory monitoring is mandatory.
- Intramuscular (IM) administration is contraindicated for lorazepam, likely due to inconsistent absorption or slower onset compared to IV administration.

Midazolam

Dose per kilogram: 0.2 mg/kg, administered via multiple routes including IV, intramuscular (IM), or intranasal (IN).
Frequency: Doses can be repeated every 5 minutes as needed.
Maximum Dose: 10 mg per individual dose.
Pregnancy Category: D.
Cautions/Comments:
- Respiratory monitoring is critical due to the sedative effects of midazolam.
- The half-life of midazolam is approximately 7 hours, making it a relatively short-acting agent compared to others, which can influence its clinical use depending on seizure recurrence risk.

All three agents are effective for rapid seizure control but share common risks, including respiratory depression, necessitating vigilant monitoring, particularly in critical care or emergency settings. Their classification in pregnancy category D highlights the need for careful consideration of maternal and fetal risks versus benefits. Midazolam offers more flexibility in administration routes, making it a practical choice in situations where IV access is not readily available.

If the seizure stops, coordinate a disposition plan and consider non-convulsive status epilepticus in patients who do not return to baseline. However, if the seizure does not stop, ensure adequate dosing of first-line therapy, then proceed to second-line therapy, and finally to third-line therapy, one step at a time [2, 28, 29].

Second-line therapy [2, 28, 29]

The second-line treatment options for epilepsy, include on a variety of antiepileptic drugs. These agents are typically used when first-line benzodiazepines are insufficient to control seizures. The table details dosing, frequency, maximum permissible doses, pregnancy categories, and relevant cautions for clinical use.

Levetiracetam

Dose per kilogram: 40-60 mg/kg administered intravenously (IV).
Frequency: Administered once over a 10-minute period.
Maximum Dose: 4500 mg.
Pregnancy Category: C (indicating that risks cannot be ruled out, but the drug may be used if benefits outweigh potential risks).
Cautions/Comments:
- Requires renal clearance, so dose adjustments may be necessary in patients with renal impairment.

Fosphenytoin

Dose per kilogram: 10-20 mg PE/kg (phenytoin equivalents) given IV or intramuscularly (IM).
Frequency: Additional 5 mg PE/kg can be administered after 10 minutes if needed.
Maximum Dose: 150 mg PE/kg.
Pregnancy Category: D (associated with risk but can be used in life-threatening situations).
Cautions/Comments:
- Can cause hypotension and dysrhythmias, requiring cardiac monitoring during administration.

Lacosamide

Dose per kilogram: 200-400 mg IV.
Frequency: An additional 5 mg/kg can be administered if necessary.
Maximum Dose: 250 mg.
Pregnancy Category: C.
Cautions/Comments:
- Can cause arrhythmias.
- Renal clearance is required, so adjustments are needed for patients with renal insufficiency.

Phenobarbital

Dose per kilogram: 15-20 mg/kg IV.
Frequency: Additional 5-10 mg/kg can be given as needed.
Maximum Dose: Not explicitly mentioned but calculated based on repeated doses.
Pregnancy Category: D.
Cautions/Comments:
- Monitor respiration closely due to the sedative and respiratory depressant effects.
- A strong P450 enzyme inducer, which can affect the metabolism of other drugs.

Phenytoin

Dose per kilogram: 15-20 mg/kg IV.
Frequency: Additional 5-10 mg/kg can be administered if necessary.
Maximum Dose: 30 mg/kg.
Pregnancy Category: D.
Cautions/Comments:
- Risk of hypotension and dysrhythmias during administration, necessitating monitoring.
- A strong P450 enzyme inducer, which impacts the metabolism of other medications.

Valproic Acid

Dose per kilogram: 20-40 mg/kg IV.
Frequency: Additional doses of 20 mg/kg can be administered if necessary.
Maximum Dose: 3000 mg.
Pregnancy Category: D.
Cautions/Comments:
- Strong P450 enzyme inducer.
- May cause hepatotoxicity and platelet dysfunction, warranting caution in patients with liver disease or coagulopathy.

The second-line agents are reserved for scenarios where first-line therapy fails to achieve seizure control. Each agent has specific risks and monitoring requirements. For example:

Levetiracetam and lacosamide are generally well-tolerated but require dose adjustments in renal impairment.
Phenobarbital, phenytoin, and valproic acid necessitate respiratory and hepatic monitoring due to their systemic side effects.
Fosphenytoin and phenytoin require cardiac monitoring due to their potential to induce arrhythmias.

The choice of agent depends on the patient’s clinical status, underlying conditions, and the safety profile of the drug.

Third-line therapy [2, 28, 29]

The third-line therapy agents for managing refractory epilepsy, particularly in patients requiring intubation, mechanical ventilation, and hemodynamic support are administered in critical care settings to control seizures when first- and second-line therapies fail. Each drug is described with its dosing regimen, frequency, maximum dose, pregnancy category, and significant precautions.

Ketamine

Dose per kilogram:
- Loading dose: 1.5 mg/kg intravenously (IV).
- Maintenance dose: 0.5 mg/kg every 3-5 minutes as needed.
Maximum Dose: Not explicitly stated, but administered as required to control seizures.
Pregnancy Category: N (Not classified).
Cautions/Comments:
- Ketamine acts as an NMDA antagonist, a unique mechanism among anticonvulsants.
- Hypotension is a potential side effect, necessitating blood pressure monitoring.

Midazolam

Dose per kilogram:
- Loading dose: 0.2 mg/kg IV.
- Maintenance dose: 0.2-0.4 mg/kg every 3-5 minutes.
Maximum Dose: 2 mg/kg for the loading dose.
Pregnancy Category: D (Risk to the fetus exists, but use may be justified in emergencies).
Cautions/Comments:
- Midazolam may cause hypotension and requires continuous hemodynamic monitoring.

Pentobarbital

Dose per kilogram:
- Loading dose: 5-15 mg/kg IV.
- Additional doses of 5-10 mg/kg may be given if required.
Maximum Dose: 25 mg/kg for the loading dose.
Pregnancy Category: D.
Cautions/Comments:
- Pentobarbital has a long half-life (22 hours), which makes it effective for sustained seizure control but may prolong sedation.
- It carries significant risks, including hypotension, ileus, myocardial suppression, immunosuppression, and thrombocytopenia, requiring vigilant monitoring in an intensive care setting.

Propofol Infusion

Dose per kilogram:
- Loading dose: 1-2 mg/kg IV.
- Maintenance dose: 0.5-2 mg/kg every 3-5 minutes as needed.
Maximum Dose: 10 mg/kg for the loading dose.
Pregnancy Category: B (Lower risk, but use must be cautious).
Cautions/Comments:
- Propofol has a short half-life (0.6 hours), allowing for rapid onset and recovery.
- Side effects include hypotension, respiratory depression, hypertriglyceridemia, pancreatitis, and the rare but potentially fatal propofol infusion syndrome. Close monitoring of triglycerides and cardiac function is necessary.

Third-line therapies are used in severe, refractory cases of epilepsy where intubation, ventilation, and hemodynamic support are required. These drugs induce deep sedation or anesthesia to suppress seizure activity effectively. Key considerations for their use include:

Ketamine: Offers a unique mechanism (NMDA antagonism), useful in resistant cases.
Midazolam and pentobarbital: Provide effective sedation but require careful respiratory and cardiovascular monitoring due to risks of hypotension and prolonged sedation.
Propofol: Its short duration of action allows for precise titration, but metabolic side effects and infusion syndrome necessitate caution.

The choice of agent depends on the clinical scenario, patient stability, and institutional protocols. These medications are used alongside comprehensive critical care support to manage complications and optimize outcomes.

Special Patient Groups

Certain notes are important to remember regarding special patient groups. In cases of seizures during pregnancy, considering the diagnosis of eclampsia is a high priority. Magnesium is the drug of choice for acute eclamptic seizures [30]. If a pregnant patient was previously diagnosed with epilepsy, a lower seizure threshold may result due to noncompliance, adjusted regimens, sleep deprivation, nausea and vomiting, or increased drug clearance. When managing status epilepticus, the risks to the fetus from the seizure are higher than the risks from the medication; therefore, manage the patient as you would a nonpregnant individual [31]. In the case of a new, non-eclamptic seizure, a workup is indicated as previously mentioned [2].

When To Admit This Patient

The decision to admit or discharge should be individualized based on the underlying illness, recurrence risk, and need for maintenance pharmacotherapy [32]. Admission for observation alongside neurological consultation should be considered for patients with an uncertain diagnosis, a history of neurological disease or other comorbidities, or in situations where follow-up is unlikely. In contrast, patients can be discharged home with early referral to a neurologist if they have normal examination findings, no significant comorbidities, no known structural brain disease, did not require more than a single dose of benzodiazepines, and are expected to comply with follow-up instructions [2].

Discharge instructions should include guidance on car driving, potentially dangerous activities (e.g., swimming, cycling, climbing ladders), and information regarding any needed follow-up [2, 33].

Revisiting Your Patient

A 22-year-old woman with a previous history of epilepsy was brought to the ER due to generalized tonic-clonic insuppressible movements of her limbs that started 15 minutes ago.

You immediately assessed the airway, breathing, and circulation and placed the patient in the lateral decubitus position to prevent aspiration, as she had a tongue injury. Blood sugar was measured using a finger stick, ruling out hypoglycemia. Lorazepam was then administered as abortive treatment.

You began taking a history from her husband. They were having lunch together when his wife suddenly started seizing, and he was unable to stop it. She had not regained consciousness since then. He mentioned that she had been inconsistent with her antiepileptic medication because she wanted to get pregnant and had read online about potential harms of the medications on a growing baby.

Her lactic acid level was high, her pregnancy test was negative, and the rest of her laboratory findings were within normal limits.

The patient was diagnosed with status epilepticus, a medical emergency requiring urgent management. The ABC approach was performed to ensure the patient’s safety, followed by the administration of benzodiazepines. If first-line therapy fails, second- and third-line therapies should be administered sequentially. Inconsistency with antiepileptic medication highlights the need for patient education and further discussion regarding her concerns and available treatment options.

Authors

Rand Redwan Al Sari

Dr Rand Al Sari is a dedicated General Physician practicing in Saudi Arabia. With a strong commitment to patient care, she is also actively engaged in medical research, staying at the forefront of healthcare advancements and integrating this knowledge into her clinical practice. Passionate about medical writing and journaling, Dr Al Sari reflects on her experiences to contribute meaningfully to the medical community, with a focus on evidence-based healthcare and improving patient outcomes.

Imad Khojah

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Keepanasseril A, Maurya DK, Manikandan K, Suriya J Y, Habeebullah S, Raghavan SS. Prophylactic magnesium sulphate in prevention of eclampsia in women with severe preeclampsia: randomised controlled trial (PIPES trial). J Obstet Gynaecol. 2018;38(3):305-309. doi:10.1080/01443615.2017.1351931
Thomas SV. Management of epilepsy and pregnancy. J Postgrad Med. 2006;52(1):57-64.
Agarwal P, Xi H, Jette N, et al. A nationally representative study on discharge against medical advice among those living with epilepsy. Seizure. 2021;84:84-90. doi:10.1016/j.seizure.2020.11.018
Engel KG et al. Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Ann Emerg Med2009 Apr; 53:454.

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Seizure (2024)

December 1, 2024December 1, 2024 ~ iEM Education Project Team ~ Leave a comment

by Ardi Knobel Mendoza, Danielle Charles-Chauvet, Erik J. Blutinger

Introduction

Seizures are caused by abnormal cortical neuronal activity that manifests as changes in alertness or neurological symptoms. While seizures account for only 1% of all emergency department (ED) visits and 3% of prehospital transports, their potential for significant morbidity undermines the importance of rapid assessment and treatment in emergency settings [1]. The etiology of seizures varies by age group, with the most common causes being fever in infants and metabolic derangements or structural abnormalities in adults over 75. This chapter will explore various seizure presentations, diagnostic assessment tools, and considerations for treatment and disposition decisions in the ED.

You have a new patient!

A 24-year-old female presents to the emergency room after being found on the street. She is minimally responsive, alert, and oriented only to herself. Her heart rate is 87 bpm, blood pressure is 141/94 mmHg, respiratory rate is 14 bpm, and she is afebrile, with oxygen saturation of 99% on room air. She has a gravid uterus with a fundal height of approximately 29 cm (11.4 inches) but is otherwise atraumatic.

What do you need to know?

Seizure Presentation and Classification

It is essential to investigate the cause and categorize the type of seizure after an acute episode to inform the diagnostic and treatment plan. Seizures are often classified as provoked, which occur within 7 days of a neurologic, metabolic, or infectious precipitator, or unprovoked, which has no association with an inciting factor. A history of seizures, febrile illness, malignancy, new medications, recreational drug use, or pregnancy can help to elucidate this. A complete neurological examination, which includes an assessment of mental status, should be performed as an altered postictal state follows most primary seizures. In addition to a change in mental status, the postictal state can present as motor deficits or paresis. Postictal paresis suggests a structural lesion as the cause of the seizure and should prompt cranial imaging [2]. Given that seizures are a manifestation of cortical neuronal activity, the extent of cortical involvement can lead to various symptoms at presentation [3].

Partial seizures involve only some of the cortex. They are classified as either simple, in which the patient is alert throughout, or complex, in which the patient has decreased alertness. Seizures can also begin as partial seizures, involving only some of the cortex, and spread to involve the entire cortex. Seizures involving the entire cortex are termed “generalized” seizures, resulting in decreased alertness. Generalized seizures are further classified based on their physical manifestations:

Absence Seizure: no collapse, automatisms (blinking, staring, lip smacking)

Tonic-clonic Seizure: collapse with stiff non-rhythmic convulsive movements.

Atonic Seizure: collapse without convulsions (similar to syncope) [4].

Febrile seizures typically occur in children 6 months-6 years of age with fevers greater than 38℃ and no neurological infection. 80% of febrile seizures are tonic-clonic in presentation, self-limiting, and do not recur after resolution of the inciting fever [5].

Eclamptic seizures are typically tonic-clonic in presentation and are considered unstable, as they carry significant mortality risk to the mother and fetus. Therefore, any pregnant patient with altered mental status and hypertension, identified as systolic >140 or diastolic >90, should be assessed for eclampsia. In cases with high suspicion of preeclampsia or eclamptic seizures, patients should be treated with magnesium for seizure prophylaxis [6].

Psychogenic seizures present similarly to generalized tonic-clonic seizures but are not associated with cortical neuronal derangements. In the ED, it is difficult to differentiate these seizures from neurogenic seizures, as there is limited access to EEG. However, psychogenic seizures present with more rhythmic and symmetric movements, patients are typically completely aware and conversant throughout, and there is no postictal state.

It is important to consider the duration of a seizure episode in all patients. Most seizures last from 30 seconds to 2 minutes. Seizures lasting longer than 5 minutes meet the criteria for status epilepticus. These patients are considered unstable, as prolonged seizure activity is associated with an increased risk of permanent brain damage. Not all patients with status epilepticus have convulsive seizures, so it is important to assess for subtle symptoms of seizure activity in the unresponsive patient, as they may have non-convulsive status epilepticus—a medical emergency.

Medical History

Thorough history taking in patients with seizure disorders is crucial for accurate diagnosis and effective management. This process involves a structured yet flexible approach to gathering relevant information, ensuring that all aspects of the patient’s condition are considered. Key components of this history include the patient’s medical background, seizure characteristics, and psychosocial factors.

Key Components of History Taking

Presenting Complaints: Document the chief complaints, including the nature, frequency, and duration of seizures [7].
Seizure Onset and Triggers: Investigate the age of onset, potential triggers (e.g., photosensitivity), and environmental factors that may provoke seizures [8].
Medical and Family History: Collect information on past medical history, family history of seizures or neurological disorders, and any relevant social history [7,9].
Psychosocial Aspects: Assess the impact of seizures on the patient’s daily life, including emotional and social challenges [8].

A comprehensive history-taking process in seizure patients is crucial for accurate diagnosis and effective management of various seizure types. By gathering essential information regarding seizure semiology, triggers, and patient-specific factors, clinicians can develop tailored treatment strategies to improve outcomes. Seizure semiology, for example, provides valuable insights into the nature of seizures, helping to classify them as either focal or generalized [10]. Detailed accounts of auras and observable signs can further indicate the anatomical origins of seizures, guiding appropriate diagnostic testing [10]. Additionally, identifying seizure triggers, such as environmental factors or specific stimuli, plays a vital role in both diagnosis and management. For instance, patients with photosensitivity may require targeted questions to uncover visual triggers that provoke seizures [8]. Together, these aspects of thorough history-taking form the foundation for effective and personalized seizure management.

When conducting history-taking in patients with seizure disorders, clinicians must be mindful of several common pitfalls that can lead to misdiagnosis or ineffective treatment. These issues often arise from inadequate questioning, overemphasizing certain symptoms, and neglecting the broader context of the patient’s experiences.

Inadequate history-taking, such as missing or incomplete accounts from witnesses, can result in misinterpreting seizure types [11]. Failing to gather detailed descriptions of seizure events, including pre-ictal and post-ictal states, may further obscure the diagnosis [12].

Additionally, an overemphasis on specific symptoms, such as those associated with focal seizures, may mislead clinicians, as these symptoms do not always correlate with the seizure type [13].

Another critical factor is the neglect of contextual elements, such as environmental triggers, which may result in missed diagnoses of reflex seizures, especially in photosensitive patients [8]. Furthermore, ignoring psychosocial aspects and the patient’s overall health can complicate the understanding of seizure disorders [14]. While advancements in technology and neuroimaging provide valuable objective data, the art of listening and thorough history-taking remains an irreplaceable cornerstone in the diagnostic process.

While a comprehensive history is essential, it is also important to recognize that some patients may present atypically, necessitating a tailored approach to history taking that considers individual circumstances and variations in symptom presentation.

Physical Examination

A comprehensive physical examination for patients presenting with seizures in the emergency department is essential for accurate diagnosis and effective management. Key components include a thorough neurological assessment, which involves evaluating consciousness, motor function, and sensory responses to identify any neurological deficits [15]. Monitoring vital signs is equally critical, as instability such as hypotension or tachycardia may indicate underlying issues requiring immediate attention [16]. Additionally, a systematic head-to-toe physical examination can help identify signs of trauma or systemic illness that may contribute to seizure activity [15].

In the emergency department, recognizing physical examination findings indicative of a severe or prolonged seizure episode is critical for timely diagnosis and management, particularly in cases of status epilepticus or non-convulsive seizures. Altered mental status, characterized by confusion, disorientation, or a prolonged postictal state, is a key finding that can suggest non-convulsive status epilepticus (NCSE) [17]. Neurological signs, such as subtle twitching, blinking, or fluctuating sensorium, may also indicate ongoing seizure activity [17]. In cases of generalized tonic-clonic seizures (GTCS), convulsive activity manifests with muscle rigidity and jerking movements, making it a more apparent diagnosis [18]. Additionally, focal seizures can result in specific neurological deficits, which may be misinterpreted as other neurological conditions. While these findings are crucial for identifying severe seizure episodes, it is important to acknowledge that some patients may present with atypical symptoms or lack overt signs of seizure activity, complicating the diagnostic process [17].

While the value of a comprehensive examination cannot be overstated, it is also important to recognize that some patients may present with atypical symptoms or underlying conditions that complicate the diagnosis. This highlights the need for a tailored approach to each case, ensuring that individual factors are carefully considered [16].

Alternative Diagnoses

The diagnosis of seizures primarily relies on the patient’s clinical history, with particular emphasis on accounts provided by witnesses. This is especially important because many seizure types involve impaired consciousness, leaving patients unaware of their episodes. Clinical findings can be supported by interictal electroencephalogram (EEG) abnormalities, although it is essential to note that such abnormalities may also occur in healthy individuals and their absence does not rule out epilepsy. It is equally critical to differentiate seizures from other conditions that may present similarly. These include syncope, such as cardiac arrhythmias or vasovagal episodes; metabolic disturbances like hypoglycemia or hyponatremia; and vascular events such as transient ischemic attacks. Additionally, migraine auras, sleep disorders like narcolepsy or night terrors, movement disorders such as paroxysmal dyskinesia, and gastrointestinal conditions like esophageal reflux in neonates and infants can mimic seizures. Psychiatric conditions, including conversion disorders, panic attacks, malingering, or episodes driven by secondary gain, must also be considered [19].

Acing Diagnostic Testing

When considering diagnostic testing such as labs and imaging, there is a lack of consensus on a set of tests required for all seizing patients. Rather, the diagnostic workup for a patient presenting with a seizure depends on a variety of factors, such as the suspected etiology of the seizure and whether the patient has a known seizure disorder or is presenting with a first-time seizure [20]. In patients with known seizure disorders, it is generally accepted test for levels of the anti-epileptic drug (AED) the patient takes, such as levetiracetam, phenytoin, carbamazepine, phenobarbital, or valproic acid. However, levels can often take hours to days to result or may not be available at a certain facility. In patients without a known seizure disorder, or if there is concern for an etiology for a seizure besides breakthrough from AED treatment, a more extensive workup is warranted. Basic testing should include a finger stick glucose, a urine or serum pregnancy test, and serum chemistry, including calcium and magnesium. Urine/serum toxicologies can also be obtained if there is concern for potential toxic ingestion as a cause. A lactic acid can be obtained, which should be markedly elevated immediately after the seizure and normalize after an hour of seizure onset [21].

A Computed Tomography (CT) Head should be obtained in all first-time seizure patients to assess for a structural lesion such as a mass, a bleed either as the etiology or sequelae of the seizure, or signs of an infection. Seizure sequelae such as significant head trauma can also be assessed with CT imaging to look for a large hematoma or skull fracture in patients who fail to return to baseline mental status after a seizure [22]. Magnetic Resonance Imaging (MRI) can be considered to reveal other diagnoses such as a brain abscess or central vascular event such as infarction; however, this imaging modality is often less available in the emergency setting and may require admission vs. outpatient referral to obtain an image [23]. Electroencephalography (EEG)is when diagnostic testing such as labs and imaging is considered, but there is a lack of consensus on a set of tests required for all seizing patients. Rather, the diagnostic workup for a patient presenting with a seizure depends on a variety of factors, such as the suspected etiology of the seizure and whether the patient has a known seizure disorder or is presenting with a first-time seizure [20]. In patients with known seizure disorders, it is generally accepted test for levels of the anti-epileptic drug (AED) the patient takes, such as levetiracetam, phenytoin, carbamazepine, phenobarbital, or valproic acid. However, levels can often take hours to days to result or may not be available at a certain facility. In patients without a known seizure disorder, or if there is concern for an etiology for a seizure besides breakthrough from AED treatment, a more extensive workup is warranted. Basic testing should include a finger stick glucose, a urine or serum pregnancy test, and a serum chemistry, including calcium and magnesium. Urine/serum toxicologies can also be obtained if there is concern for potential toxic ingestion as a cause. A lactic acid can be obtained, which should be markedly elevated immediately after the seizure and normalize after an hour of seizure onset [21].

Risk Stratification

The presence of comorbidities plays a critical role in the risk stratification, prognosis, and management of epilepsy, highlighting the need for a holistic approach to patient care. In the emergency department, recognizing these comorbidities is crucial for tailoring immediate interventions and ensuring acute and comprehensive follow-up care. Studies reveal that 60-70% of adults and 80% of children with epilepsy experience multimorbidity [25]. Among patients with senile epilepsy, 81% have at least one comorbidity, with neurological (61%) and cardiovascular (45%) conditions being the most prevalent [26]. Emergency clinicians must remain vigilant for these conditions, as they may exacerbate seizure episodes or complicate acute management. These comorbidities significantly impact seizure outcomes, as patients with neurological and psychiatric disorders face a higher risk of recurrent seizures and reduced likelihood of achieving seizure freedom [26]. Conditions like depression and anxiety are particularly associated with a more severe course of epilepsy [27], and their identification in the emergency setting can guide referrals for further psychiatric evaluation. Additionally, multimorbidity is linked to lower health-related quality of life and increased healthcare costs due to frequent hospitalizations [25]. Cognitive and psychiatric comorbidities often impair daily functioning more than the seizures themselves [28], necessitating a multidisciplinary approach starting from the emergency department. Addressing these comorbidities, however, has been shown to improve overall health outcomes and enhance the quality of life for patients, emphasizing the importance of comprehensive, patient-centered care [28].

Management

The most important intervention in a patient actively seizing is ensuring adequate brain oxygenation. The airway should be protected via maneuvers that include rolling the patient on their side, jaw thrusts, applying a nasopharyngeal airway, applying supplemental oxygen, and preventing aspiration with suction as needed. Oxygenation status should be monitored with continuous pulse oximetry and capnography when possible.

Providers should also anticipate the impending decompensation of the clinical course and the need for intubation by preparing airway equipment, medications, and IV access, which will be discussed later in the chapter. Along with oxygenation, patients must be protected from injury, e.g., from falling out of bed and preventing trauma.

Most seizures stop on their own within one to two minutes of onset, but the longer the seizure lasts, the less likely it is to stop on its own and can become self-sustaining.

Seizures that are continuous or intermittent, lasting more than 5 minutes without recovery of consciousness, are known as status epilepticus. Medical therapies to terminate a seizure are divided into three stages based on escalation of need and inability to terminate the seizure.

Benzodiazepines are considered first-line agents in terminating seizures, followed by second-line agents such as Levetiracetam, Valproate, Phenytoin, and Fosphenytoin [29]. The third-line medications are infusions of benzodiazepines, propofol, or barbiturates, prepared for likely intubation with paralytics and continued infusions [30].

The following lists these medications by stage, dose, and considerations [31, 32]:

Midazolam (1st Line Agent – Benzodiazepine)

Loading Dose:
- 10 mg IM or 0.1-0.2 mg/kg IV.
Maintenance Dose: 0.001 mg/kg/min.
Pediatric Dose:
- IV or IN: 0.2 mg/kg (max 5 mg).
- IM:
  - <13 kg: 0.2 mg/kg.
  - 13-39 kg: 5 mg.
  - 39 kg: 10 mg.
Considerations:
- IM dosing can be used if no IV is established.
- Acts faster than Lorazepam but has a shorter duration.
- May cause respiratory depression and hypotension.

Diazepam (1st Line Agent – Benzodiazepine)

Loading Dose: 10 mg over 2 minutes. Repeat every 5-10 minutes to a max of 30 mg.
Maintenance Dose: N/A.
Pediatric Dose: 0.15 mg/kg IV.
Considerations:
- May cause respiratory depression and hypotension.

Levetiracetam (2nd Line Agent)

Loading Dose: 60 mg/kg (up to a max of 4,500 mg), infused over 10 minutes.
Maintenance Dose: Same as the loading dose.
Pediatric Dose: Same as loading dose.
Considerations:
- If the patient weighs >75 kg, the dose is 4.5 g.
- If seizures stop, continue to give Levetiracetam to prevent recurrence.

Phenytoin (2nd Line Agent)

Loading Dose: 18-20 mg/kg with a max rate of 50 mg/min.
Maintenance Dose: N/A.
Pediatric Dose: N/A.
Considerations:
- Cardiac monitoring is necessary for QRS complex widening.

Fosphenytoin (2nd Line Agent)

Loading Dose: 15-20 mg/kg with a max rate of 150 mg/min.
Maintenance Dose: Same as loading dose.
Pediatric Dose: N/A.
Considerations:
- Cardiac monitoring is necessary for QRS complex widening.

Valproate (2nd Line Agent)

Loading Dose: 20-40 mg/kg over 10 minutes. Repeat if needed.
Maintenance Dose: Same as loading dose.
Pediatric Dose: Same as loading dose.
Considerations: N/A.

Propofol (3rd Line Agent)

Loading Dose: 1-2 mg/kg IV over 5 minutes (max load 10 mg/kg).
Maintenance Dose: 50-80 mcg/kg/min (3-5 mg/kg/hr) as an infusion.
Pediatric Dose: N/A.
Considerations:
- May cause respiratory depression and hypotension.

Phenobarbital (3rd Line Agent)

Loading Dose: 10-15 mg/kg bolus up to 60 mg/min.
Maintenance Dose: 120-240 mg every 20 minutes.
Pediatric Dose: N/A.
Considerations: N/A.

Midazolam (for 3rd Line use) (3rd Line Agent)

Loading Dose: 0.2 mg/kg IV.
Maintenance Dose: 0.1-2 mg/kg/hr.
Pediatric Dose: N/A.
Considerations:
- Can be used in patients with hypotension.

Once the provider considers 3rd line medications and starting infusions, they should prepare for intubation as the patient is likely in status epilepticus, requiring continued medication and airway protection. Induction medications for intubation are often the same medications listed above in the 3rd stage of treatment, such as propofol or midazolam, and can be on board before paralytics. Paralytics are used to stop the seizure-like activity and aid in intubation, but it is important to remember that they are not meant to terminate the seizure. Patients can still have seizures despite the lack of tonic-clonic seizure activity such as NCSE. Rocuronium is the preferred paralytic agent as it is not associated with the hyperkalemia seen in succinylcholine, which is a risk for patients seizing for an extended period who could develop rhabdomyolysis. Rocuronium paralysis lasts much longer, which should be a consideration when monitoring for further seizures with EEG.

Finally, other conditions can cause seizures or seizure-like activity that require their own treatment strategies, which are discussed below:

Eclampsia, a life-threatening condition often associated with pregnancy, is treated with magnesium to control seizures, benzodiazepines for acute management, and blood pressure control to address underlying hypertension. For seizures due to isoniazid toxicity, the recommended treatment is pyridoxine (vitamin B6), which counteracts the drug’s neurotoxic effects. In cases of hypoglycemia, seizures can be managed by administering Dextrose 50% in Water (D50W) to restore blood glucose levels rapidly. Hypocalcemia, another potential seizure trigger, requires the administration of calcium gluconate or calcium chloride to normalize calcium levels. For seizures induced by hyponatremia, 3% hypertonic saline is used to increase serum sodium levels safely.

In cases of toxicity from aspirin, tricyclic antidepressants (TCAs), or lithium, hemodialysis is indicated to effectively remove the offending agents from the bloodstream. For seizures caused by meningitis, prompt initiation of appropriate antibiotics is critical to address the underlying infection and prevent further complications.

Special Patient Groups

Pediatrics

Seizures in pediatric patients can present with diverse etiologies ranging from febrile seizures to more serious underlying conditions such as intracranial infections, metabolic disturbances, or congenital disorders. In children under 5, febrile seizures are the most common cause of convulsions and are generally self-limited, though they require careful differentiation from more serious causes like meningitis or encephalitis. Clinical reasoning should prioritize a detailed history, including the onset of the seizure, vaccination status, and any family history of epilepsy or neurodevelopmental disorders. Laboratory tests and imaging may be indicated if there is a high suspicion of an underlying structural or metabolic issue, such as in children with a prolonged postictal state or a first-time seizure without a clear precipitant. In the emergency department (ED), rapid assessment of the child’s airway, breathing, and circulation (ABCs) is paramount, along with ensuring the seizure is appropriately controlled, often with medications like lorazepam or diazepam. Close follow-up is necessary to assess for recurrent seizures or potential neurological sequelae.

Geriatrics

Seizures in elderly patients often present a diagnostic challenge due to the overlap with other common age-related conditions, such as syncope, transient ischemic attacks (TIA), or dementia-related behavioral changes. In this population, new-onset seizures should prompt an urgent evaluation for reversible causes, including cerebrovascular events, metabolic disturbances (such as hyponatremia or hypoglycemia), brain tumors, or infections like meningitis or encephalitis. Seizures in older adults may also be a manifestation of progressive neurodegenerative diseases, including Alzheimer’s or Parkinson’s disease. Emergency management in the ED should focus on stabilizing the patient while considering potential drug interactions, as elderly patients are more likely to be on multiple medications that may lower the seizure threshold (e.g., antipsychotics, antidepressants, or antihypertensives). Antiepileptic drug (AED) therapy initiation, while necessary in recurrent or long-duration seizures, must be approached cautiously due to age-related pharmacokinetic changes and the increased risk of side effects. A thorough evaluation for underlying causes, including neuroimaging and laboratory tests, is critical.

Pregnant Patients

Seizures during pregnancy present unique challenges in both diagnosis and treatment. The differential diagnosis includes pregnancy-specific conditions like eclampsia, in addition to the possibility of preexisting epilepsy or new-onset seizures due to metabolic derangements or intracranial pathology. In a pregnant patient with a seizure, the clinical priority is to ensure both maternal and fetal well-being. Eclampsia, a severe complication of preeclampsia, must be ruled out, as it presents with generalized tonic-clonic seizures and may lead to maternal and fetal morbidity if not promptly treated. Once eclampsia is excluded, consideration should be given to other causes such as hypoglycemia, cerebrovascular accidents, or drug toxicity (e.g., withdrawal from anticonvulsant medications). Emergency management in the ED should prioritize seizure control, typically with benzodiazepines, while avoiding teratogenic medications. Magnesium sulfate is the treatment of choice for eclampsia. Fetal monitoring should be initiated, and careful planning for delivery may be required depending on the severity of the condition and gestational age. The clinical approach should balance the need for immediate seizure control while minimizing risks to both the mother and fetus.

When To Admit This Patient

Few definitive practice guidelines are available to emergency physicians making disposition decisions for seizure episodes. However, all critically ill patients must be admitted to the inpatient setting since overall risk assessment is important for deciding whether to safely discharge patients home. For alternative clinical presentations, the physician should reliably assess whether the patient’s overall presentation warrants further medical interventions in a clinical setting.

For emergency physicians, seizure recurrence, morbidity, and mortality are useful measures to consider for safe discharge. Studies suggest that seizure recurrence most often depends upon EEG findings and the underlying cause—normal EEG and undetectable cause are associated with lower recurrence rates [33]. With positive neuroimaging findings (e.g., structural findings), initiating AED therapy for first-time seizures is recommended given a high 1-year recurrence risk of up to 65% [34].

Any patients with abnormal neurologic signs or symptoms who have not fully recovered from their seizure should not be discharged. Other important clinical benchmarks are the presence of normal vital signs, CT head imaging, EKG, basic lab results (especially renal function and blood counts), and follow-up. As part of the physician’s risk assessment of the patient’s overall condition, social factors must also be taken into account: lack of follow-up care, history of being lost to follow-up, and insufficient assistance available at home should all weigh towards admitting the patient for further monitoring (and possible seizure workup).

Generally, stable patients are those who return to their baseline mental status, do not exhibit any new neurological deficits, have no significant lab result abnormalities, and remain at low risk for recurrent seizure activity in the short term. Coordinating reliable follow-up is important, and all patients should be educated about the “red flag” signs and symptoms that warrant urgent evaluation and treatment.

Revisiting Your Patient

Altered mental status in the gravid, hypertensive patient is concerning for eclampsia. This patient should be started on 2mg of Mg as seizure prophylaxis. Obstetrics should be consulted as urgent delivery via cesarean section is the definitive treatment for this patient’s seizures. After delivery, the patient should be monitored closely for postpartum eclamptic seizures, which can occur up to 6 weeks postpartum.

Authors

Ardi Knobel Mendoza

Ardi Mendoza, MD is a resident at the Mount Sinai Hospital Emergency Medicine Program. He is interested in Health System and Emergency System Strengthening and local partner/local government-led collaborations. He has prior experiences in the field of Global Surgery while at Rutgers Robert Wood Johnson Medical School, assessing financial risk protection from impoverishing and catastrophic expenditure due to surgical care in the Colombian Healthcare System. He lived in Lima, Peru for a year working with Peruvian researchers at the University Cayetano Heredia as a research coordinator helping to develop a point-of-care diagnostic screening tool for Autism using eye-tracking technology.

Danielle Charles-Chauvet

Danielle Charles-Chauvet, MD is an Emergency Medicine resident at the Mount Sinai Hospital in New York. She is deeply invested in medical education and health disparities and, in affiliation with Harlem Children's Zone, has led several community-based educational initiatives to address these disparities. She designed and taught a course entitled Health and Structures of Oppression at Brown University's medical school. Her dedication to education earned her the 2022 National Outstanding Medical Student Award from the Academic College of Emergency Physicians and the 2021 Medical Education Award from the Society of Academic Emergency Medicine. She is currently working to expand her impact internationally by building Haiti's medical education infrastructure.

Erik J. Blutinger

Erik J. Blutinger, MD, MSc, FACEP is a full-time emergency physician at Mount Sinai Queens Hospital in New York City and Medical Director to the Community Paramedicine program at Mount Sinai Health Partners. He completed his residency training at the University of Pennsylvania, Master's at the London School of Hygiene & Tropical Medicine, and has worked on a variety of health initiatives in quality and patient experience with formal leadership training in Quality Improvement (QI). Erik has worked in multiple national healthcare systems and underserved communities, including townships in South Africa and Guatemala, Bhutan, India, and Austria.

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Burgess M, Mitchell R, Mitra B. Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review. Acad Emerg Med. 2022 May;29(5):649-657. doi: 10.1111/acem.14391. Epub 2021 Oct 1. PMID: 34534387.
Teran F, Harper-Kirksey K, Jagoda A. Clinical decision making in seizures and status epilepticus. Emerg Med Pract. 2015 Jan;17(1):1-24.
Harden CL, Huff JS, Schwartz TH, Dubinsky RM, Zimmerman RD, Weinstein S, Foltin JC, Theodore WH; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007 Oct 30;69(18):1772-80. doi: 10.1212/01.wnl.0000285083.25882.0e. PMID: 17967993.
Gelisse P, Crespel A, Genton P, Jallon P, Kaplan PW. Lateralized Periodic Discharges: Which patterns are interictal, ictal, or peri-ictal? Clin Neurophysiol. 2021 Jul;132(7):1593-1603. doi: 10.1016/j.clinph.2021.04.003. Epub 2021 Apr 27. PMID: 34034086.
Rosenthal Seizures, Status Epilepticus, and Continuous EEG in the Intensive Care Unit. Continuum (Minneap Minn). 2021 Oct 1;27(5):1321-1343. doi: 10.1212/CON.0000000000001012. PMID: 34618762.
Gaitatzis A, Majeed A. Multimorbidity in people with epilepsy. Seizure. 2023;107:136-145. doi:10.1016/j.seizure.2023.03.021
Cao, Z., Li, Y., Liu, S. et al.Clinical characteristics and impact of comorbidities on the prognosis of senile epilepsy in Southwest China: a retrospective cohort study. Acta Epileptologica 6, 11 (2024). https://doi.org/10.1186/s42494-024-00153-8
Kanner, A.M., Ribot, R. and Mazarati, A. (2018), Bidirectional relations among common psychiatric and neurologic comorbidities and epilepsy: Do they have an impact on the course of the seizure disorder?. Epilepsia Open, 3: 210-219. https://doi.org/10.1002/epi4.12278
Mula M, Coleman H, Wilson SJ. Neuropsychiatric and Cognitive Comorbidities in Epilepsy. Continuum (Minneap Minn). 2022;28(2):457-482. doi:10.1212/CON.0000000000001123
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012 Feb 16;366(7):591-600. doi: 10.1056/NEJMoa1107494. PMID: 22335736; PMCID: PMC3307101.
Falco-Walter JJ, Bleck Treatment of Established Status Epilepticus. J Clin Med. 2016 Apr 25;5(5):49. doi: 10.3390/jcm5050049. PMID: 27120626; PMCID: PMC4882478.
Brophy GM, et : Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 17:3-23, 2012.
Seizure: Emergency Medicine, Second Editor; Adams, James G., MD, 2013, 2008 by Saunders, an imprint of Elsevier Inc. Book Chapter 99
Berg AT, Shinnar The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991;41:965–72.
Jagoda A; Gupta, K. “The Emergency Department Evaluation of the Adult Patient Who Presents with a First-Time ” Emergency Medicine Clinics of North America, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/21109101/.

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Journal Club 10/17/22: Global Burden of Disease

April 3, 2023March 23, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

The Economic Impact of Ebolavirus in West Africa: A Burden the Size of Iceland by Andrew L. Mariotti

Between 2014 and 2016, West Africa experienced an Ebola virus epidemic that resulted in 28,000 cases, 11,000 deaths, and a loss of up to $32.6 billion in gross domestic product. To put this in perspective, America’s 2021-2022 flu season culminated in 9 million cases, 5,000 deaths, and a loss of up to $8 billion in GDP. In other words, a single Ebola infection represents a nearly 1200 times greater economic cost, emphasizing the intense strain this disease places on West African nations.

Factors precipitating these costs are multi-faceted and stem not only from the increased morbidity of Ebola but also from structural constraints. The 16 countries of West Africa represent a GDP of $726 million and struggle with a human capital index (see figure below) of 0.40, nearly 0.17 points under the global average. Given this set of conditions, it’s no wonder a disease as serious as Ebola can lead to losses greater than the size of Iceland’s economy ($24.4 billion GDP).

While many strategies to ameliorate these issues emphasize the importance of developing new infrastructure and creating jobs, it’s worth considering how treating Ebola – and reducing the associated disease burden – could palliate a gargantuan economic burden holding this region back from development. How to accomplish this aim would require an entirely new blog post. However, the thought of what a $32.6 billion investment could return for the future growth and development of these underserved populations is worth consideration.

Further Reading:

Promoting Health, Preventing Disease: Is There an Economic Case?; a policy summary from the World Health Organization, Organization for Economic Cooperation and Development, and European observatory on Health Systems and Policies. https://www.euro.who.int/__data/assets/pdf_file/0004/235966/e96956.pdf
Prioritizing Health: A Prescription for Prosperity; McKinsey and Company July 2020 Report. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/prioritizing-health-a-prescription-for-prosperity
Stein, F., & Sridhar, D. (2019). Back to the future? Health and the World Bank’s Human Capital index. BMJ, l5706. https://doi.org/10.1136/bmj.l5706

Discussion Questions:

What barriers to effective Ebola treatment and containment would provide the greatest benefit to individuals in endemic regions were it to be realistically mitigated?
How does the way we think about the importance of treating epidemics change when considering the economic impact it has on a country and could decreasing disease burden be an effective strategy for helping developing nations become more industrialized?

Chapter 4: Global Health and the Global Burden of Disease by Kelsey Yenney

In this chapter, a focus was placed on common terms used to describe the health of a population as well as discuss two ongoing projects that guide policymakers when setting priorities. Throughout this post I will refer to the ‘global burden of disease’; authors in this book have provided the definition as “quantity of diseases/conditions AND their impact on the population”.

Describing the health of populations is done in terms of descriptive statistics and there are many reasons to quantify the burden of disease. The health of a population must be measured and understood for the healthcare system to adequately respond. Quantifying the burden of disease allows for planning, policy making, executing delivery and program evaluation. For example (as used by the author of this chapter), the Minister of Health of Malawi may learn that there were 260 new cases of tuberculosis per 100,000 people in one year. Given that the population at the time was 15.5 million, she can plan that 40,300 people will be diagnosed and treated in her country in the coming year to achieve universal coverage of TB. Descriptive statistics allow policy makers, practitioners, and other healthcare providers to attempt to stay “one step ahead” of the ebbs and flows of epidemiology.

Understanding the burden of disease requires disease surveillance. In 1992, the World Bank commissioned WHO to quantify the global burden of disease; until that time, there was historically insufficient data with which to estimate the burden of disease in many countries, thus leading to an insufficient understanding of the global burden of diseases. In those studies, it was determined that less than 30% of the data on disease and death came from medically certified documents. A new project in 1994 (“Global Burden of Disease”) looked at 107 conditions and over 400 sequelae or secondary outcomes from disease. Diseases were grouped into different categories and countries were grouped based on their “established market economies”. Later in 1994, the term “DALY” (Disability-Adjusted Life Year) was created which describes the number of years of life that is lost or affected by disease.

When thinking about the transitions of epidemiology, Abdel Omran named four significant concepts that describe observed shifts in the types of diseases that affect a population as economic conditions improve. For example, malnutrition becomes less frequent as a country gains food security, water sanitation, etc. However, as infrastructure and economy grow, diseases caused by cigarette smoke, processed foods, etc. can increase. The four stages of population health described by Omran were as follows:

Age of Pestilence and Famine: high mortality due to infectious disease and starvation
Age of Receding Pandemics: life expectancy increases as food security; access to housing and clean water improves
Age of Degenerative and Manmade Diseases: fertility rate decreases, infant mortality continues to fall; major causes of death are non-communicable diseases
Age of Delayed Chronic Disease: primary prevention of disease

The above stages were used by policymakers to create a prioritized stepwise process to promote the cheapest and easiest approach to targeting a country’s biggest threat based on where they “fell within the stages”. However, diseases do not occur in a stepwise approach and each country has a diverse range of disease burden. All nations, no matter the GDP, must prevent and plan for infectious disease, mental health, non-communicable disease, etc.

In 1977, Milton Weinsten and William Stason proposed a formula that became known as cost-effectiveness to make choices between different medical interventions. They proposed that a health intervention was only cost-effective if it was to be under 3x the per capita health costs. This meant that in the US, for example, at the time, a health intervention would be cost-effective if it was less than several thousand dollars because the per capita health expenditure of the US healthcare system is high. However, in impoverished countries, a health intervention would need to fall within $5-15 to be deemed cost-effective. This does not fall anywhere close to the ideals of equity. Using cost-effectiveness as a sole model to reduce global burden of disease severely limits the right to health as it does not consider the many aspects of disease.

Discussion Questions:

What are some conditions/public health concerns that may not be prevalent at the time but can be planned for?
For example, no matter what stage of population health a country may be in, infrastructure for flooding may be put in place. What are some major limitations you can see with the proposed cost-effectiveness model?
What are some ways that countries are or could be dealing with increasing chronic disease in settings still with large burdens of transmissible disease?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these two topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Andrew L. Mariotti, MS3

University of Colorado School of Medicine

Kelsey Yenney, MS3

Washington State University
Elson S. Floyd College of Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, PGY2

Blog Editor
University of Florida - Jacksonville

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Resources

Drame, M.L., P. Ferrinho, and M.R.O. Martins, Impact of the recent Ebola epidemic with pandemic potential on the economies of Guinea, Liberia and Sierra Leone and other West African countries. Pan Afr Med J, 2021. 40: p. 228.
de Courville, C., et al., The economic burden of influenza among adults aged 18 to 64: A systematic literature review. Influenza Other Respir Viruses, 2022. 16(3): p. 376-385.
Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 4: Global Health and the Global Burden of Disease

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Journal Club 9/19/22: Medical Tourism

March 27, 2023March 23, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Telemedicine in Low-Resource Settings by Rachel Patel

Telemedicine is defined as the delivery of health care and the exchange of health-care information across distances.

The types of telemedicine are as follows:

Live, two-way (or real-time) synchronous audio and video allows specialists, local physicians, and patients to see and hear each other in real-time to discuss conditions
Store-and-forward sends medical imaging such as X-rays, photos or ultrasound recordings to remote specialists for analysis and future consultation
Remote patient monitoring collects personal health and medical data from a patient in one location and electronically transmits the data to a physician in a different location

The advantages of telemedicine in low-resource settings include:

Increasing health access across geographical barriers
Cost-effectively providing services, from radiology to dermatology to at least some of the millions of patients who lack adequate healthcare
Contact precautions (e.g. COVID-19 pandemic)
Surveillance and monitoring of medical emergencies, generating health data to inform international aid programs and policies
Interconnected network of data sharing as well as funding for international crises

Limitations include:

Patients who have emergent health conditions, or need a physical exam or laboratory testing for medical decision making
If sensitive topics need to be addressed, especially if there is patient discomfort or concern for privacy
Limited access to technological devices (e.g., phones, tablets, computers) or connectivity

Discussion Questions:

What are some of the ethical implications of telemedicine?
How do you see telemedicine factoring into medical care as we move forward in a post-COVID world?
Is there a place for telemedicine in emergency medicine?

The Roots of Global Health Inequity by Grace Bunemann

** A short blog post & presentation are far too brief of formats to discuss this extensive topic adequately. The following is an overview of Chapter 1 from Dr. Joia S. Mukherjee’s book entitled An Introduction to Global Health Delivery. **

To simply explain LMIC (lower middle-income country) Health Systems today, it is important to review the history of slavery and colonialism which led to years of resource extraction ultimately resulting in weak health systems seen in LMIC countries today.

Prior to World War II, the conduct of a government against its own people was considered a matter of national sovereignty, however global opinion changed following the liberation of the Nazi concentration camps. After WWII, it was believed that all people, regardless of their country of origin, have an inalienable set of human rights. These principles were upheld in the Universal Declaration of Human Rights in 1948.

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

The same European countries that were championing human rights had little issue with the continuation of colonialism and denying those who were colonized their human rights. Importantly, only four independent African countries were able to vote for the Declaration (South Africa, Egypt, Ethiopia, and Liberia).

In 1978, the International Conference on Primary Health Care was held in Alma Ata (currently Almary, Kazakhstan). The conference hosted 600 representatives from the 150 WHO member states and aimed to discuss models for care delivery and develop solutions for people living without access to health care.

In parallel to the Cold War, socialist republics advocated for government funds to deliver on the promise of health as a human right by building public health systems with doctors, nurses, and hospitals while capitalist states argued that health systems could not be built until economic growth occurred and reasoned that volunteers could be used to deliver basic health services in impoverished countries.

It is important to note a majority of delegates advocated for the public provision of health as a human right and the Alma Ata Declaration is the result. It advocated for health as a human right and included the need to address the social factors related to ill health, such as lack of food, water, and sanitation. The declaration set modest yet concrete goals like 90 percent of children should have weight for an age that corresponds to reference values, every family should be within a 15-minute walk of potable water, and women should have access to medically trained attendants for childbirth.

The concept that health demanded more resources than those available within an impoverished country’s budget and that health should be financed through international collaboration were radical notions. Several factors impacted the Alma Ata Declaration including physician opposition, Cold War geopolitics, and neoliberal reforms.

In 1979, a proposed alternative to the Alma Ata Declaration was published in the New England Journal of Medicine entitled ‘Selective Primary Health Care — An Interim Strategy for Disease Control in Developing Countries.’ It praised the goals of Alma Ata as laudable, but ascertained the objective was unrealistic given the impoverishment of those countries with the highest disease burden. This publication countered that it is more realistic to target scarce resources to prevent and control the spread of diseases that account for the highest mortality and morbidity. Selective Primary Health Care became the new standard for global health efforts for years to come.

“It is impossible to understand global health delivery without understanding the destructive history of slavery, colonialism, and neoliberalism that left governments impoverished and unable to fulfill the right to health.”

Wrap up!

Thank you to our authors and presenters!

Rachel Patel, MS4

Rutgers Robert Wood Johnson Medical School

Grace Bunemann, MS4

Campbell University School of Osteopathic Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Resources

Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine 2020; 328; 1679–1681
Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. Journal of Pain and Symptom Management 2020; https://doi.org/10.1016/j.jpainsymman.2020.03.019external icon
Ohannessian R, Duong Ta, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill 2020;6(2):e18810 doi: 10.2196/18810.
Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, Caffery LJ. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare 2020; DOI: 10.1177/1357633X20916567
Tuckson, R., Edmunds, M., Hodgkins, M. Telehealth. New England Journal of Medicine 2017; 377:1585–1592. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMsr1503323
Tolone S, et al. Telephonic triage before surgical ward admission and telemedicine during COVID-19 outbreak in Italy. Effective and easy procedures to reduce in-hospital positivity. International Journal of Surgery 2020; 78 : 123–125.
Perez Sust P, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill 2020;6(2):e19106) doi: 10.2196/19106
Project ECHO: Provides resources to connect frontline healthcare professionals with experts for distance learning and consultation
Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 1: The Roots of Global Health Inequity.
Boston 677 HA, Ma 02115 +1495‑1000. ALMA-ATA at 40: A Milestone in the Evolution of the Right to Health and an Enduring Legacy for Human Rights in Global Health. Health and Human Rights Journal. Published September 6, 2018. https://www.hhrjournal.org/2018/09/alma-ata-at-40-a-milestone-in-the-evolution-of-the-right-to-health-and-an-enduring-legacy-for-human-rights-in-global-health/
Alma-Ata 40 years on | Health Poverty Action. http://www.healthpovertyaction.org. Accessed February 22, 2023. https://www.healthpovertyaction.org/news-events/alma-ata-40-years-on/

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Project Proposal 12/20: Developing a Community Education Program to Combat Envenomation in India

March 9, 2023February 24, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Problem Statement

The WHO classified snakebite envenomations as an NTD in 2017 for causing enormous suffering, disability, and premature death worldwide. Bites by venomous snakes can cause paralysis, fatal hemorrhages, irreversible kidney failure, tissue damage and more, leading to permanent disability and limb amputation. Over half the world’s envenomation events and deaths occur in India; this epidemic has been termed “the neglected famer’s tragedy” due to a disproportionate increase in agricultural areas, and a “therapeutic black hole” due to ineffective or unavailable interventions within the region. With 5.8 billion people at risk of encounters, and 2.7 million reported cases of envenomings, it is estimated that there are between 81,000 to 138,000 deaths and countless more debilitating injuries each year in the country.

The WHO developed the Snakebite Envenoming Strategic Plan which calls for a 50% reduction in mortality and disability caused by snakebite envenoming by 2030 through 4 goals:

Empower and engage communities.
Ensure safe, effective treatment.
Strengthen systems.
Increase partnerships, coordination, and resources through strong collaboration.

Project Proposal

Our project focuses on the first WHO goal; Empower and engage communities. However, it includes aspects of all the 2030 goals by creating an education system that will help prevent envenomations and arm the community with a safe plan to approach such events to reduce morbidity and mortality. The project will focus on educating and engaging community leaders, to promote sustainability and community engagement. These community leaders will be trained to teach and discuss topics including characteristics of venomous and non-venomous snakes, dispelling, and discussing common misconceptions surrounding proper envenomation management, first-aid, initial management, and stabilization. Community leaders and community members will also be connected with national partners like the National Snake Bite initiative (NSI) as well as international partners like WHO through The Platform, an interactive Application that allows the public to participate in reporting events and venomous snake sightings, slowly creating a regionalized database.

Qualitative surveys before and after educational campaigns on community knowledge, perceptions, sociocultural and spiritual understanding and depiction of snakes and snakebite envenoming can help to measure how receptive communities have been to the program. Since envenomation events are underreported, it is difficult to assess any qualitative differences (hospital admission events), however, since we plan to implement this program on a community-by-community basis it may be possible to investigate numbers through local health ministries, clinics, and hospitals to assess different trends before and after program implementation.

Based on the WHO Snakebite Working group budget we estimate this project would not cost more than $15,000 USD, with much of the funds allocated to program creation, program coordinators and educators, community leaders, and program creation. The WHO allocated over $140 million USD over 10 years worldwide to this problem and $650,000 USD to community education in 10 countries. Using this logic, we estimated that more than $65,000 would be allocated to a country like India. If this project were to pilot its educational campaign in a specific region, we estimate no needing more than $15,000 USD.

By partnering with national partners on the ground like the NSI and community leaders who will continue to train and educate, this program will become sustainable through working with those that are inherently invested in more positive outcomes through education in their own communities. Additionally, the WHO’s Platform application will be promoted during educational programming to further engage and empower the community to take an active role in their own education and safety by sharing photos of potentially venomous snake sightings along with their location data. By promoting effective interventions involving education surrounding proper venomous snake identification, snake education, medical interventions, and effective reporting this program will reduce snake bite deaths and long-term disability and empower at risk communities in India to take their safety into their own hands.

Discussion

After presenting the proposal to the group, we engaged in discussion on this proposal. One of the questions that sparked deep and insightful conversation was “Why is the focus of this project education, and not ensuring that are adequate and strategically placed life saving anti-venom available?”

Below is a summary of the most pertinent ideas posed:

1. Many companies producing have stopped/gone out of business and even if there was plentiful supply it would still not help with preventing or addressing the problem when most cases of snakebite envenomation that occur are not reported.

2. With an educational campaign the people are able to take power into their own hands.

3. The cost benefit ratio of this method is extremely low. Many people reside far away from any form of health care and in India, the cost of initial treatment has been reported to be as high as USD$ 5,150, which makes investments in anti-venom unsustainable.

References

https://www.who.int/health-topics/snakebite#tab=tab_1
https://www.who.int/activities/preventing-and-controlling-snakebite-envenoming
https://www.who.int/publications/i/item/9789241515641
https://www.who.int/india/health-topics/snakebite
https://www.nature.com/articles/d41586-020-03327-9#ref-CR
Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008;5(11):e218. doi:10.1371/journal.pmed.0050218
Yanamandra U, Yanamandra S. Traditional first aid in a case of snake bite: more harm than good. BMJ Case Rep. 2014;2014:bcr2013202891. Published 2014 Feb 13. doi:10.1136/bcr-2013-202891
Chauhan V, Thakur S. The North-South divide in snake bite envenomation in India. J Emerg Trauma Shock. 2016;9(4):151-154. doi:10.4103/0974-2700.193350
International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMS LP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Nikkole Turgeon, MS4

University of Vermont Larner College of Medicine

Racheal Kantor, MS4

Medical School of International Health, Ben-Gurion University

Nicholas Imperato, MS4

Philadelphia College of Osteopathic Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Project Proposal 12/20: Establishing an Objective Risk Assessment for Road Traffic Accidents in Ghana

March 1, 2023March 8, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Background

Worldwide, road traffic accidents (RTAs) account for about 1.3 million fatalities and, on average, 3% of a given country’s GDP. Over half of these deaths occur among vulnerable road users, such as pedestrians, cyclists, and motor cyclists. Approximately 93% of all of the world’s RTA-associated mortalities occur in middle- to low-income countries, even though they have only 60% of the world’s vehicles. Road traffic injuries cause considerable economic losses to individuals, their families, and to countries as a whole that take a considerable toll even years or decades after the incident occurred. These losses arise from the cost of treatment as well as lost productivity for those killed or disabled by their injuries, and for family members who need to take time off work or school to care for the injured.

The country of Ghana experiences, on average, 2,000 RTA-associated deaths and 14,000 RTA associated injuries annually. At the Korle-Bu teaching hospital in Accra, Ghana, the largest health facility and teaching hospital in Ghana and the main referral site for all of southern Ghana, between 2016 and 2017, 62% of deaths in the hospital’s accident center were related to RTAs. These RTA-associated deaths and injuries cost the country around 1.6% of its GDP, which amounts to over $1.3 million per year.

In the early 2000s, the Ghanaian government began to recognize the serious socio-economic impact of RTAs on its country. To address the issue, the National Road Safety Commission (NRSC) was established to collect data on RTAs and propose solutions and policies in response. Various data was collected, such as the number of annual deaths and injuries and road user classes associated with these fatalities. Data collected demonstrated that, in Ghana, the road user class with the highest share of fatalities was consistently pedestrians (824; 39.5%) followed by motorcycle users (437; 21%) and bus occupants (364; 17.5%). Considering RTAs in the context of emergency care, studies showed that, again at the Korle-Bu Teaching Hospital, almost 40% of emergency care visits were from RTAs, followed distantly by falls and interpersonal violence. Of the victims that died upon or after arrival to the hospital, 50% were pedestrians, 31% were passengers, and 18.7% were motorists.

From the numbers provided, it’s readily apparent that deaths caused by injuries, and, specifically, RTA-associated injuries, rank among the top ten causes of death in Ghana. It was concluded that underlying drivers of this issue were broadly two-fold: there was a high proportion of RTA-associated injuries due to poor road conditions and unregulated driving practices, and emergency care providers were lacking in proper, formal trauma-based care, both prehospital and when they arrived to an emergency care facility.

To address these shortcomings, various sizable mitigation measures were adopted by Ghana’s government in an attempt to decrease the number of RTAs and their associated costs. In 2004, Ghana established a National Ambulance Service (NAS), providing over 200 ambulances staffed with formally trained, BLS-certified EMTs for pre-hospital care. Ghana’s first EM residency program was established in 2009, followed one year later by its first 2-year Emergency Nursing degree program. More recently, in 2019, the NRSC passed the National Road Safety Authority Acts that were designed to promote and mandate best road safety practices, both in road users and road developers. However, despite these resolutions, RTAs and their associated injuries and deaths continue to remain consistently high in the country.

A literature review of available research on Ghanian RTAs revealed several limitations in the studies. While the NRSC has been instrumental in collecting RTA data and devising protocols to mitigate RTAs, there is still a lack of detailed, objective research on RTAs in Ghana. Additionally, there are significant inconsistencies in the source of the data and whether it is a registry-based report or a population-based study. The causes of accidents are not well-documented, and there is limited data available detailing where the majority of RTAs occur aside from the regions most heavily affected. According to data from 2016, over 75% of RTAs occur in 5 regions (Ashanti, Greater Accra, Eastern, Central and Brong Ahafo), of which four of the five regions correspond to the four most populous regions (with the exception of Ahafo, which is the least populated). Interestingly enough, however, about 60% of RTA fatalities were in non-urban sections of the road networks. Despite this information, we were unable to find details regarding where the specific accidents occur within each region.

Research collected by the University of Ghana’s School of Public Health identified the following risk factors that were highly associated with RTAs: stop-light violations, improper signaling, speeding. However, we believe that the study used to determine these risk factors relied too heavily on subjective analysis, leading to potentially erroneous and biased data. Therefore, we propose utilizing traffic cameras for gathering objective data in areas with a high burden of RTAs. This analysis will allow local authorities to identify risk factors that lead to RTAs, resulting in the utilization of emergency medicine services.

In short, an objective method of identifying common risks, causes, and associations of RTAs is crucial in order to decrease morbidity and mortality as well as the need for emergency care. This is especially important, as Ghana spends over $130 million USD each year on RTA-related injuries alone.

Project Proposal

We believe one way to do this is to utilize traffic cameras that are already in place in these high traffic areas to analyze accidents. As the infrastructure is already in place for surveillance – all we need to do is collect and analyze the footage, which has limited costs associated with it. We would need to pay salary to 1-2 data analysts in order to analyze the information. If more cameras were needed, this would cost anywhere from $65-80,000 USD per camera installation. After installation and retrieval of the camera data, what information will we collect? First, we would like to identify what specific intersections and roadways are involved in RTAs. We also would collect temporal statistics such as day of the week, month and time of day as well as weather conditions. The type and number of vehicles involved in the accident as well as identifying whether the drivers are local versus nonlocal are also important characteristics. Lastly, we would look at whether drivers violated traffic laws such as running a redlight or were speeding as well as being in the incorrect driving lane.

The data collected from this proposal can be used to promote infrastructure changes to lessen the risk of future RTAs. In particular, the installation of crosswalks have been proven to mitigate incidences of motor accidents. According to a 2017 study, 68% of pedestrian fatalities from RTAs in Ghana are related to “pedestrian crossing behaviors.” However, the study was limited in its ability to deduce further information from these incidents, such as the causality of the accident. The review of the stop light camera footage from the event would allow the local government to determine if more facilities such as crosswalks may be beneficial to install in populated intersections.

Conclusion

The high prevalence of RTAs in Ghana is a public health concern that dramatically burdens the emergency medical community. We believe that the data collected from traffic cameras can be used to more concretely understand the risk factors that lead to motor accidents in Ghana. Ultimately, this information can be used to improve infrastructure features to mitigate risk of future accidents.

References

https://www.cdc.gov/injury/features/global-road-safety/index.html
Blankson PK, Lartey M. Road traffic accidents in Ghana: contributing factors and economic consequences. Ghana Med J. 2020 Sep;54(3):131. doi: 10.4314/gmj.v54i3.1. PMID: 33883755; PMCID: PMC8042801.
Blankson PK, Nonvignon J, Aryeetey G, Aikins M. Injuries and their related household costs in a tertiary hospital in Ghana. Afr J Emerg Med. 2020;10(Suppl 1):S44-S49. doi: 10.1016/j.afjem.2020.04.004. Epub 2020 May 26. PMID: 33318901; PMCID: PMC7723915.
Zakariah A, Stewart BT, Boateng E, Achena C, Tansley G, Mock C. The Birth and Growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017 Feb;32(1):83-93. doi: 10.1017/S1049023X16001151. Epub 2016 Dec 12. PMID: 27938469; PMCID: PMC5558015.
https://ugspace.ug.edu.gh/bitstream/handle/123456789/36413/Injury%20Patterns%20and%20Emergency%20Care%20in%20Road%20Traffic%20Accidents%20in%20Accra.pdf?sequence=1&isAllowed=y

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Holly Farkosh, MS4

Marshall University Joan C. Edwards School of Medicine

Andrew McAward, MS2

Marshall University Joan C. Edwards School of Medicine

Tram Lee, MS3

University of Oklahoma Health Sciences Center

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Project Proposal 12/20 :Creating Culturally Appropriate Mental Health Care Programs After Disasters

February 22, 2023February 21, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Mental health conditions are the leading cause of disability worldwide, accounting for an estimated 175.3 million years lost to disability (Figure 1). Inequalities in access to or quality of mental health care globally are directly related to social, structural, and economic determinants. Increasingly, research suggests that these socioeconomic inequalities lead to health issues not just for disadvantaged populations but for all those involved in unjust or unequal societies. In addition, most of our information on global access to mental health care is limited to formal psychiatric care, which discounts other forms of local or indigenous healing practices.

Disasters have countless impacts on communities and can cause stress due to feelings of powerlessness, loss of community life and culture, and destruction and physical displacement. An estimated 1 in 3 highly exposed trauma survivors may experience post-traumatic stress disorder (PTSD), and 1 in 4 may experience major depression. Psychological distress, which does not meet the criteria for another formal psychiatric diagnosis, is nearly universal after exposure to a disaster and deserves significant attention as well.

It is also crucial to ensure that mental health responses after disasters are conscious of unique local contexts. Previously, priorities in disaster responses have primarily been defined by mental health professionals mostly by nations of the Global North, which gives insufficient attention to locally-defined priorities. These established programs focus mainly on major neuropsychiatric disorders as defined by Western professionals and assume that the features, courses, and outcomes will mirror those seen in the cultures where they were initially developed. Existing programs and literature also tend to focus on PTSD, with other forms and manifestations of psychological distress falling through the cracks. This focus on applying formal diagnosis and treatment assumes that they are generalizable across cultures and may marginalize indigenous forms of healing that could be vital to the community.

Key Priorities

With these concerns in mind, we want to highlight some key priorities in creating a culturally sensitive mental health care program in the post-disaster setting. First, we need to remember that systemic factors such as structural violence and poverty are important determinants of mental health outcomes (Figure 2). Thus it is imperative to first support efforts addressing basic socioeconomic needs and promote physical safety of the population. In addition, mental health programming may be carried out in tandem with medical colleagues addressing other problems to increase coverage and decrease the need for additional infrastructure.

Figure 2: Proximal and distal factors of the social determinants of mental health with sustainable development goals mapped onto the different domains.

In assessing the community’s mental health needs, there should be an effort to learn and adapt to the local context, as an individual’s response to suffering is likely influenced by the religious, spiritual, and moral context of the local community. In addition, classification systems used in mental health evaluation (i.e., DSM-5) should be modified to integrate the knowledge of culturally specific idioms of stress, taking into account also differences related to class, gender, age, sexuality, minority/majority position. Lastly, special attention must be given to those with existing psychopathology as these individuals are at risk of having worse outcomes in response to disasters.

Proposed Solution

Guided by these principles, we proposed examples of programming components that partner with the local community and integrate an understanding of local resources and traditions of healing.

Work with psychologists, community health workers, and local religious leaders to facilitate memorial services in response to possible losses in the community.
Promote education on when and where to seek service, especially in social settings that communities frequently gather.
Develop programs that go beyond the toolkit of professionals and mobilize indigenous resources and family-specific social activities to encourage people to also rely on support from immediate social networks.
Partner with specialists to support task-shifting to local non-specialist providers.
Establish screening protocols for aid workers and staff working in disaster settings as these individuals are also at risk for mental health issues.

We want to have a continuous evaluation of the program in four outcomes areas, each with different indicators:

Relevance (indicated by population need and cultural and contextual fit)
Effectiveness (indicated by mental health outcome)
Quality (indicated by adherence, competence, and attendance)
Feasibility (indicated by coverage and cost)

While some of the indicators, such as coverage, helps to define operational characteristics of the program, other factors, such as cultural and contextual need, support the program by engaging with local stakeholders. Information regarding these indicators can be obtained using various methods, including community surveys, national health system records, cohort studies, and observational studies.

Though the world’s mental health burden is experienced heavily in low and middle-income countries (LMICs), often only a tiny portion of the annual operating health budgets in these countries will go toward addressing mental health issues. For example, the Emerald (Emerging mental health systems in LMICs) study, which was a multinational study conducted to assess the infrastructural and policy needs for expanding mental health services in Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda, revealed that in some LMICs, there is less than $0.25 per person per year available for mental health budgeting. In addition to limited resources and finances, mental health programs face other challenges related to sustainability, such as poorly trained staff and a lack of understanding about service delivery processes and quality improvement. High turnover of senior-level policymakers can prevent longitudinal advocacy and agenda-setting, and low community participation can also be a barrier.

While the exact cost for our program is difficult to predict given system collapse and displacement of populations in the post-disaster setting, here we provide an estimation of a possible budget using the operating budget of the NGO Médecins Sans Frontières (MSF) in 2020 as a starting point.

MSF Operating Budget 2020 = €550,000,000 Euros, with 80% spent on programming spending (€440,000,000)
- €440,000,000 spent across 10 countries = €44,000,000/country in 2020
- *Presuming 2% for mental health budget allocation = €880,000 for mental health budget/country/year
~350,000 Mental Health Consultations across 10 countries
- ~35,000 Mental Health consultations annually per nation engaged
€880,000 / 35,000 consultations = €25/consultation (used for medications, counseling, etc)

Even assuming just 2% of the operations budget is allocated to mental health programming, it can be estimated that major NGOs may be able to make a more significant fiscal investment in mental health than what public services can currently offer in LMICs. In the emergent setting, the surge of financial resources from these agencies towards affected groups presents new opportunities and motivation for development. Additionally, the destruction or collapse of health systems amidst destabilization may provide opportunities to build more equitable and person-centered care systems. Furthermore, media attention can stir public interest and political willpower to dedicate more resources to mental health treatment systems.

Historically, international health actors have not prioritized the transition of care from transient emergent systems to nascent local infrastructure. Thus two types of investment are needed to ensure a smooth transition and subsequent strengthening of the local health system. Initially, startup investment from aid organizations is needed to maintain operating budgets amidst transitions. Then continuous funding for long-term service delivery from health departments or public agencies is required to promote infrastructure longevity and tackle some of the previously mentioned system-level challenges impeding sustainability of programming.

Summary

In summary, our current understanding of and approach to global mental health focus on priorities does not pay sufficient attention to local priorities and marginalizes indigenous healing techniques. Guided by an understanding of the social determinants of mental health, at-risk populations in disaster settings, and the crucial importance of adapting to local contexts, we proposed several priorities in infrastructure support, assessment, and intervention when establishing culturally sensitive mental health care programs. Outcomes of the program will then be evaluated in its relevance, effectiveness, quality, and feasibility and used to modify the program in response to changing needs in the post-disaster setting. While the increase in support from NGOs during times of disaster will likely result in increased resources available for mental health programming, transition, and down-scale of post-disaster services to local health systems will never be sufficient nor sustainable without addressing systems-level problems.

References

Bischoff, R.J., Springer, P.R., Taylor, N. (2017). Global Mental Health in Action: Reducing Disparities One Community at a Time. Journal of Marital and Family Therapy, 43, 276-290. doi: 10.1111/jmft.12202
Kirmayer, L.J., Pedersen, D. Toward a new architecture for global mental health. Transcultural Psychiatry. 2014;51(6):759-776. doi: 10.1177/1363461514557202
North, C.S. Pfefferbaum, B. Mental Health: Response to Community Disasters: A Systematic Review. JAMA. 2013;310(5):507-518. doi: 10.1001/jama.2013.107799
Jordans, M., & Kohrt, B. (2020). Scaling up mental health care and psychosocial support in low-resource settings: A roadmap to impact. Epidemiology and Psychiatric Sciences, 29, E189. doi:10.1017/S2045796020001018
Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, Haushofer J, Herrman H, Jordans M, Kieling C, Medina-Mora ME, Morgan E, Omigbodun O, Tol W, Patel V, Saxena S. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry. 2018 Apr;5(4):357-369. doi: 10.1016/S2215-0366(18)30060-9.
Bredström, A. Culture and Context in Mental Health Diagnosing: Scrutinizing the DSM-5 Revision. J Med Humanit 40, 347–363 (2019).
Raviola G, Eustache E, Oswald C, Belkin GS. Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions. Harv Rev Psychiatry. 2012;20(1):68-77. doi:10.3109/10673229.2012.652877
Semrau, Maya, et al. “Strengthening Mental Health Systems in Low- and Middle-Income Countries: The Emerald Programme.” BMC Medicine, vol. 13, no. 1, 10 Apr. 2015, 10.1186/s12916-015-0309-4. Accessed 7 May 2019.
Epping-Jordan, JoAnne E, et al. “Beyond the Crisis: Building Back Better Mental Health Care in 10 Emergency-Affected Areas Using a Longer-Term Perspective.” International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Alison Neely, MS4

Albert Einstein College of Medicine

Luxi Qiao, MS4

Washington University School of Medicine

Jacob Reshetar, MS4

University of Minnesota School of Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Journal Club 3/21/22: Mental Health in the International Community

January 25, 2023January 12, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Prevalence of burnout among university students in low- and middle- income countries: a systematic review and meta analysis - presented by Jonathan Kajjimu

Burnout is a form of distress that manifests with features of emotional exhaustion, depersonalization, and reduced personal/professional accomplishment. Emotional exhaustion or unsuccessful coping with stressors, is the fatigued feeling that develops as one’s emotional energies are drained. Depersonalization refers to a student’s indifference, negative or cynical attitude. Reduced personal accomplishment is a negative self-evaluation of one’s abilities which manifests itself with feelings of failure. University education is an intrinsically demanding time which puts university students at risk for burnout, coupled with other burnout risk factors such as individual/personal factors and extracurricular factors. Burnout causes significant physical, emotional, psychological, and spiritual damage to students.

However, from this article there had been paucity of and discrepancies in data on the overall prevalence of burnout in university students from low- and middle-income countries (LMICs). Students pursuing health-related programs in mostly high-income countries (HICs) had been mostly studied previously.

In this review, 55 articles were included, with a total of 27,940 (female: 16,215, 58.0%) university students from 24 LMICs. The Maslach Burnout Inventory (MBI) was found to be the most widely used tool for measuring burnout in 43 studies (78.2%). The pooled prevalence of burnout was 12.1% (95% CI: 11.9–12.3; p = < 0.001). Pooled significant prevalence of emotional exhaustion, cynicism, and reduced personal/professional efficacy were 27.8% (95% CI 27.4–28.3), 32.6% (95% CI: 32.0– 33.1), & 29.9% (95% CI: 28.8–30.9) respectively. Burnout pooled prevalence was highest among the African region at 35.4%, followed by the Asian region at 30.2%, and the European region at 20.7%.

Figure 1: Forest plot for the prevalence of burnout in LMICs

In this review, burnout rates found in LMICS were lower than those in HICs, which the author believed to be due to publication bias. Authors further recommended low cost interventions that were needed more in low income countries than in middle income countries for managing burnout. These included mindfulness practices, yoga exercises, and group discussions. The current COVID-19 pandemic was also highlighted as having been found to put university students at a higher risk of burnout. Consequences of burnout in students include absenteeism, drop out, reduced academic performance, depression, alcohol and drug abuse, suicide, professional impairment and dissatisfaction, increased incidence of errors and near-misses.

Discussion Questions:

How can medical schools focus more on mental health of medical students?
How can we ensure that medical students always have their wellbeing in check?
Do you think medical students actually get burnt out or are they just morally injured?

Some of the great recommendations received were having wellness days, “Opt out sessions”, and free counselling sessions in medical school for openly bringing out mental health issue discussions. However, one student confidently believed it would be difficult for schools to focus on mental health of students despite other discussants’ optimism.

Med students can: Focus on reducing energy drain. Identify what you can change – and what you can’t. Align your goals, values and beliefs. Set limits and delegate. Create new challenges that are aligned with your values. Give yourself frequent breaks. Seek support. Monitor your energy level and emotional state. Eat energy and brain foods. Pace yourself. Build problem-solving skills. Lighten the situation with humor. Having regular physical exercise.

Medical schools can: Advocate for student autonomy i.e. ability to influence student environment and schedule control. Provide adequate support services such as counselling, secretarial, administrative, social work, and financial. Encourage collegial work environments, healthy relationships and sharing of common goals. Minimize school-home interference. Promote proper work-life balance. Ensure vacation time and limit overtime. Establish mentoring. Consider periodic sabbaticals.

Kaggwa MM, Kajjimu J, Sserunkuma J, Najjuka SM, Atim LM, Olum R, et al. (2021) Prevalence of burnout among university students in low- and middle-income countries: A systematic review and meta-analysis. PLoS ONE 16(8): e0256402. https://doi.org/10.1371/journal. pone.0256402

Mental Health in the International Community - Presented by Alexander Gallaer

Mental illness is a topic that is still gaining awareness, acceptance, and understanding in many parts of the world. While western medicine, most notably the DSM-V, has sought to carefully categorize and define mental disease, the definition of what constitutes mental illness is still very much disputed globally. Unfortunately, many global populations may suffer from unaddressed mental health struggles as a result of these varying attitudes. Notably, post-traumatic stress disorder (PTSD), as defined by the DSM-V, is a disease that has an enormous global burden. As emergency physicians increasingly become the sole health care providers, especially in marginalized populations, it is important to have awareness of what groups may need special attention or follow up to diagnose or address underlying PTSD. Some of these groups include male military veterans (lifetime prevalence of 30.9% (1)), emergency healthcare providers (up to 15.8% (2)), and, most notably here, refugee populations (up to 62% in some Cambodian cohorts (3)). Early recognition of symptoms and swift referral of patients to mental health services as soon as symptoms are identified could alleviate long term disease burden and lead to improved outcomes (4). Because refugee populations are high risk, providers can consider routinely screening for symptoms.

Discussion Questions:

How would you approach treating a mental health crisis in an individual who does not believe such issues exist, or that such disease processes can affect them?
How can we raise awareness of PTSD in populations with traditionally low recognition of mental illness? Should we do this?

References:

1) Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593.

2) Bahadirli S, Sagaltici E. Post-traumatic stress disorder in healthcare workers of emergency departments during the pandemic: A cross-sectional study. Am J Emerg Med. 2021 Dec;50:251-255. doi: 10.1016/j.ajem.2021.08.027. Epub 2021 Aug 14. PMID: 34416516.

3) Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States.JAMA. 2005;294(5):571.

4) Fanai M, Khan MAB. Acute Stress Disorder. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-

The Unique Challenges of Mental Health and Multidrug Resistant Tuberculosis- Presented by Ellen Chiang

Calculating disability adjusted life years (DALY) aims to quantify disease burden in terms of both mortality and morbidity. This calculation is an important tool in global health work and as with all tools, it has limitations. Attempts to quantify disability from mental health disorders demonstrate the constraints of the DALY.

Our understanding and definition of what classifies a mental illness is influenced by our sociocultural context. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is therefore impacted by politics and prejudice. While DALY calculations include sex and gender as weighted factors, many other social factors are not considered. Additionally, much of the medical research published in the major psychiatric journals center on Euro-American study populations, which limits the cross-cultural application of findings.

Without full consideration of what is not captured by our quantitative measurement of choice, global health interventions can have unintended, significant consequences. The book chapter highlights this by discussing the emergence of multidrug resistant tuberculosis (MDTRB) from the implementation of the DOTS protocol in Peru, which was supported largely by the cost effectiveness paradigm.

Global health experts should understand the limitations of the DALY when using it to identify priorities and create and evaluate interventions. Remaining aware of what falls outside of the DALY can help create more context appropriate health interventions and new measurements that factor in important social dimensions of disease burden

Discussion Questions:

Is it possible to create a metric for disease burden that accounts for social context?
When implementing a large-scale health intervention, what are some ways to maintain the flexibility needed to address unexpected challenges?

References:

Ji, Jianlin, Arthur Kleinman, and Anne Becker. “Suicide in Contemporary China: A Review of China’s Distinctive Suicide Demographics in Their
Sociocultural Context.” Harvard Review of Psychiatry 9, no. 1 (2001): 1– 12.

Anand, Sudhir, and Kara Hanson. “Disability-Adjusted Life Years: A Critical Review.” Journal of Health Economics 16, no. 6 (1997): 685– 702.

Sen, Amartya. “Missing Women: Social Inequality Outweighs Women’s Survival Advantage in Asia and North Africa.” British Medical Journal 304, no. 6827 (1992): 587– 588.

Wrap up!

We thoroughly enjoyed the discussion sparked by these three mentees and are proud to be to present a brief summary of their work here! Please stay tuned for more article summaries and details about our upcoming meetings. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Jonathan Kajjimu, MS5

Mbarara University of Science and Technology

Alexander Gallaer, MS4

University of Connecticut School of Medicine

Ellen Chiang, MS4

UNC Chapel Hill

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Keep in Touch:

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Journal Club 1/10+1/31/22: Sustainability and Language Justice

January 18, 2023February 17, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Tropical Diarrheal Illnesses in Children by Ying Ku

Tropical diarrheal illnesses (TDIs) are major health concerns around the world, especially in resource-limiting countries, resulting in approximately 500,000 child deaths annually. TDI is a gastrointestinal infection caused by pathogens that are prevalent in the tropical regions, with diarrhea being the main presentation. Most commonly, these diseases are spread by contaminated food and water due to inadequate sanitation and poor hygiene. Among various microorganisms that can result in TDIs, Rotavirus and E. coli are the most common agents causing moderate to severe diarrhea in children in resource-limiting countries. Some common signs and symptoms are diarrhea, nausea & vomiting, cramps, fatigue, fever, and chills. However, TDIs may result in death secondary to severe dehydration. When assessing TDI patients, it is crucial to determine dehydration status and identify the type of diarrhea (watery or dysentery) given the different treatment approach. The most important treatment is rehydration with oral rehydration salts (ORS). ORS can be made with: 1 L water + ½ tsp salt + 6 tsp sugar. The more detailed treatment algorithm can be found in the Clinical Care Guideline for Integrated Management of Childhood Illness. Strategies in preventing TDIs can be summarized into blocking common transmission factors such as feces, fingers, flies, fields, fluids, and food via proper sanitation and hygiene. Lastly, we can help with this global health concern via donation/fundraiser for the organizations working to improve access to safe drinking water and sanitation, as well as being involved in projects to help develop prevention and control strategies in different locations.

Discussion Questions:

What are the challenges in promoting better hygiene in developing countries?
Despite the widespread use of ORS, mortality associated with severe dehydration in children remains significant. What are some factors contributing to this challenge?

Language Barriers and Epistemic Injustice in Healthcare Settings by Savanna Hoyt

Introduction
- Language injustice is one of the most significant challenges facing national health systems.
- Language barriers between patients and practitioners can have significant adverse impacts on quality of care.
- Every phase of the healthcare process relies on effective communication.
Language and Healthcare: Complex Dynamics
- In diverse societies, healthcare challenges stem from the fact that while language is a human commonality, it manifests through a wide range of languages.
- Culture influences every aspect of illness, including interpretations of symptoms, explanations of illness, seeking help, adherence to treatment, and patient-provider relationships.
Linguistic Epistemic Injustice:
- An example of testimonial injustice (misjudgement of how a person speaks), is when a patient and physician do not share a first language, but must communicate in it due to a lack of translation services.
- Different concepts of illness across languages can result in hermeneutical injustice (misjudgement of what a person says).
Linguistic Epistemic Humility:
- Linguistic epistemic injustice can be countered by linguistic epistemic humility.
- In healthcare, epistemic humility involves becoming aware of your own capacities within your own language, with other languages, and actively searching for ways to overcome language barriers.
- When considering patient-physician relationships across language barriers, the physician can facilitate positive relationships and deliver better care by recognizing their own language ability, acknowledging language needs of the patient, and attempting to correctly pronounce the patient’s name.

Conclusion
- A more language-aware healthcare process can further advance the health of the general population, ensuring practice and research are carried out in a more equitable manner.

Discussion Points:

How can we as future physicians work towards eliminating language barriers in healthcare?
What are the possible outcomes of addressing language barriers in healthcare?

Social Forces and their Impact on Health Presented by Sreenidhi Vanyaa Manian

In medical school, we learn about the causes of various diseases usually falling into categories of infectious, genetic or immune-mediated processes. However, when it comes to causes often it is enclosed under the broader umbrella of social forces that impact health—defined as the social ‘determinants’ of health.

“The unequal distribution of power, income, goods , services, globally and nationally, the consequent unfairness in the immediate visible circumstances of people’s lives-their access to healthcare, schools, and education , their conditions of work and leisure , their homes , communities, towns and cities – and their chances of leading flourishing life.”

We witness these social forces everyday and millions across the globe experience its impact on health. Insufficient food, inadequate safe water and discrimination based on race, gender and ethnicity are obstacles on the road to health.

Rudolph Virchow investigated a typhus epidemic which he later called the ‘artificial epidemic’ as he identified the role played by factors such as lack of access to food, education, employment, as well as political isolation with the spread of disease rather than the microbe itself.

“Medicine is a social science and politics (is) nothing but medicine on a grand scale”

Who LIVES? Who dies?

Structural violence creates and perpetuates ill health, suffering and death. It is an unfair and evil entity that victimizes the underserved communities creating a lasting impact on their emotional, social, physical and mental well-being. Structural violence is inherently political and is fundamentally about resources and power.

Poverty constrains choice, often in a brutal fashion.

Communities with lower socioeconomic status have been shown to have higher rates of accident, drug use depression and anxiety compared to those in higher socioeconomic groups.

In 1848 Rudolf Virchow identified the lasting impact of social forces on health. How do we combat this? The answer is biosocial approach to global health wherein the healthcare provider attempts to understand the patient’s experiences, including the social forces present in the life of the person; as well as the impact of illness in the context of his/her daily life. This necessitates a deep historical, political and social understanding of the community

We all have heard the quote “Health is Wealth.” But we must understand that some degree of wealth is required in order to attain health that gives people a fair chance on their journey to liberty, peace and the pursuit of happiness.

Discussion Points:

Any social movements that you know that led to better chances for good health in your community?
What will you suggest (given the power) to the government to mitigate adverse social determinants?
What do you think is the greatest barrier to achieve equitable health?
During history taking, what are the other questions that can be asked to the patient for a more holistic approach to treatment?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Ying Ku, MS3

Campbell University School of Osteopathic Medicine

Savanna Hoyt, MS2

Northeast Ohio Medical University

Sreenidhi M Vanyaa, MS4

PSG Institute of Medical Sciences and Research

Halley J Alberts, PGY2

Blog Editorial Lead
University of South Carolina
Prisma Health Midlands

Resources

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Journal Club 11/29/21: Ethics of Humanitarian Work

April 6, 2022May 14, 2022 ~ Global EM Student Leadership Program ~ Leave a comment

POCUS in Resource-Limited Settings presented by Holly A. Farkosh

POCUS, or point-of-care ultrasound, is a focused exam performed and interpreted by an examiner usually at the bedside, that must answer a specific question (is there a pleural effusion, yes or no?). The diagnosis must also be 1) relevant to consecutive treatment decision-making and 2) easily and accurately recognizable by the physician applying the US without extensive training.

There are many advantages to using POCUS in a resource-limited setting, including but not limited to:

– Portability; relatively inexpensive starting at $2000

– Limited access to other diagnostic imaging equipment (XR, CT, MRI–all of which require additional training to read and use/operate)

– Rapid, noninvasive

– No ionizing radiation exposure

– Improves success and safety of bedside procedures

– Can easily be repeated, quickly, and without increasing radiation exposure, especially if clinical status or physical exam findings change

– Particularly cost-effective (in the United States) in pediatric appendicitis and trauma (found to have decreased time to OR, decreased CT scans in the pediatric population, shortened length of hospital stay)

Some of the disadvantages include:

– Requirement of formal training

– Issue of how to power/charge and reliable access to this

– Handheld US requires a smartphone

– Supplies (US gel)

– Upkeep and repair

– Image portability (inability to print or save images for patients to share with other healthcare providers)

– Ethical considerations?

Tying it all Together: Ethical Considerations for POCUS in Resource-Limited Settings

– Cost-effectiveness: some resources are deemed too expensive

– Resource limitations and differences in standard of care between the United States and other countries

– Practitioners who may be teaching US may have limited knowledge of practicing in resource-limited settings, or there may be discrepancies in both knowledge of using the technology/resources available as well as the common presenting diseases in that region

– Sustainability: in relation to implementing training programs– what happens after instructors leave? Requires adequate planning for system integration and ongoing supervision and skill maintenance

– Limited capacity and inconsistent availability of follow-up care; screening without available treatment

Discussion Questions:

What other ethical considerations are there to implementing POCUS in resource-limited settings?

– Advantage: lack of need for significant infrastructure; skills can quickly be acquired; real-time video training/support between the United States and other countries

– Limited support for continued supervision/continual mentorship on improving skills; sustainability of training programs

– Potential costs of training

What to do when you come across findings not consistent with physical exam– how to advocate for further diagnostics/evaluation?
Using US for central lines: lack of US availability; no formal US training; need to teach how to use US, but also important to teach things such as sterile prep/technique

Why do we have a desire to work in Global Health? By Cody Ritz

Chapter nine from Reimagining Global Health: An Introduction aims to explore a few different answers to this complex question. It’s possible that many of our desires to work in Global EM stem from some of the moral frameworks or values systems presented in these pages. The chapter lays them out as such:

Depending on your own personal motivations, you may identify with one, many, or none of these moral frameworks or value systems. This list is not meant to be exhaustive, and it barely scratches the surface of the many nuances included in each of these philosophies. While we could go to much greater lengths to wholly explore these schools of thought, I believe the greatest benefit in naming them is not solely for the purpose of categorization. Rather, by taking the time to compare these sources of motivation, we can equip ourselves with a vocabulary and mindset that helps give form to our innermost determinations. While this form develops, we can begin to understand the foundations of our own interest to work in not only global health but medicine at large. As we come to better understand ourselves, let us hope this allows us to better understand others as well.

Discussion Points:

With which of these frameworks/value systems do you identify personally? – One? Multiple? None of them at all? – and how has that framework informed your own perspective and approach to global health?
Imagine that you’re in an interview for a position you want in the future and the interviewer asks—Why do you have these interests in global health when there is already great need within your own backyard?— How do you respond? In what ways could you explain your motivations within the frameworks discussed in this chapter?

Wrap up!

Thank you to our authors and presenters!

Holly Farkosh, MS4

Marshall University School of Medicine

Cody Ritz, MS2

Drexel University College of Medicine

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Journal Club 11/08/21: Resource Equity in a Pandemic

February 23, 2022March 10, 2022 ~ Global EM Student Leadership Program ~ Leave a comment

The Global Burden of Schistosomiasis presented by Farah Mechref

Endemic in 74 countries across Africa, the Middle East, South America, and Asia, schistosomiasis is a neglected tropical disease caused by flatworms or blood flukes known as schistosomes. About 440 million individuals are infected with these trematodes, which reside in the blood vessels of their definitive host and lead to different clinical manifestations depending on the species. In regions endemic for schistosomiasis, the most prevalent form of the disease is
chronic schistosomiasis, resulting from repeated immunological reactions to eggs trapped in organ tissues. Infection begins when individuals enter bodies of water that contain contaminated snails that have released infectious cercariae. These cercariae penetrate the skin of the human host and produce an allergic dermatitis at the site of entry or a “swimmer’s itch.” Antigens are then released from their eggs, which stimulates a granulomatous reaction composed of T cells, macrophages, and eosinophils, resulting in the clinical disease.

Acute schistosomiasis typically presents with sudden onset of fever, malaise, myalgia, headache, fatigue, and abdominal pain lasting 2–10 weeks, with eosinophilia noted on lab findings. Chronic infection cause granulomatous reactions and fibrosis in affected organs, which results in clinical manifestations
that include:

-In S. mansoni and S. japonicum: upper abdominal discomfort that then shows palpable, nodular hepato-spenlomegaly with eventual development of portal hypertension from fibrosis of portal vessels and resulting ascites and hematemesis from lethal esophageal varices.

-In S. haematobium: hematuria, which is so endemic that it’s thought to be a natural sign of puberty for boys and confused with menses in girls, with eventual development of squamous-cell carcinoma of the bladder.

Currently, the only control measures available include (1) mass treatment with Praziquantel (Biltricide) in communities where schistosomiasis is endemic, (2) introduction of public hygiene programs to provide safe water supplies and sanitary disposal of stool and urine, (3) snail eradication programs using molluscicides, and (4) vaccination development to create a more durable and sustained reduction in transmission.

Discussion Questions:

Knowledge of transmission and preventative measures play an important role in schistosomiasis control, what other endemic conditions could be better tackled with improved patient education?
With 230 million actively infected patients and another 200 million with latent infections, is a vaccine worth the resource distribution or should funding go towards expanding the anti-parasitic classes available for treatment?

Resource Equity in a Disease Outbreak by Alison Neely

The Ebola virus disease of 2013-2016, centered in West Africa, was considered one of the most threatening cases of infectious disease outbreak in modern history up until the emergence of Covid-19 in 2019. Due to the high case fatality rate of Ebola, the core element of the outbreak response was effective case identification and rapid isolation; treatment centers were quickly overwhelmed and experienced limited bed supply and staff time. A study drawing from interviews with senior healthcare personnel involved in this Ebola outbreak response aimed to identify the ethical issues involved in such a response and to create a framework of ethical guiding principles for future responses.

The framework proposed after analysis of the participants’ interviews was split into four categories: community engagement, experimental therapeutic interventions, clinical trial designs and informed consent. Community engagement stood out as a key element both in the framework and in the journal club discussion that followed. Engagement can include promotion of collaboration and open dialogue, incorporation of community insights into decision-making processes, encouragement of transparency, building trust, and reflecting on context-specific cultural values. As future physicians with special interest in global medicine, these ideas of respecting cultural context and complete inclusion of the local community in response efforts were highlighted as very relevant to our future practice.

Discussion Points:

Have the principles presented here been followed in the global response to the Covid-19 pandemic?
Our discussion also focused on the parallels and differences between this Ebola response and the global response to the Covid-19 pandemic, calling attention to the ways that the response both followed and diverged from the framework presented in this article. As the idea of a disease outbreak has become part of daily conversation in the last 2 years, investigations and discussions such as this will become increasingly relevant and important. We also touched on the idea that our global response to Covid-19 may have been very different, and potentially weaker, if the Ebola outbreak had not occurred when it did.

Wrap up!

Thank you to our authors and presenters!

Farah Mechref, MS4

Texas Tech University Health Sciences Center

Alison Neely, MS4

Albert Einstein College of Medicine

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Journal Club 10/18/21: The Global Burden of Disease

December 13, 2021March 10, 2022 ~ Global EM Student Leadership Program ~ Leave a comment

Global Health and the Global Burden of Disease presented by Denise Manfrini

Global burden of disease is the quantity of disease (conditions, illnesses, injuries) and their impact on a population. The impact is measured in disability-adjusted life years (DALYs), which is the years of life lost from premature death and years of life lived in less than full health. There are other metrics used as well to compare countries, such as incidence, prevalence, mortality, and fertility rate.

In order to determine these metrics to measure global burden of disease and see where a country’s health system should focus, disease surveillance is required. This led to the creation of the Global Burden of Disease (GBD) Project in 1992. It aims to develop a consistent way to estimate disease burden in eight global regions (established market economies and formerly socialist economies) using the metrics described above, particularly the DALY. The project initially quantified 107 conditions and over 400 sequelae and has been expanding and updating its findings in the following years. This level of detail has allowed tracking of disease changes over the years and given insight into which interventions are effective. Initial results have shown high disease burden, premature mortality, and health disparities when comparing established market economies and impoverished countries; notably, developing countries suffered more from infectious and parasitic diseases, respiratory infections, and maternal and perinatal disorders. Developed countries suffered more from diseases due to poor lifestyle, such as cardiovascular disorders. Results from 2019 indicate shifts. Overall health is improving worldwide since those results in 1994 (GBD 2019 Diseases and Injuries Collaborators 2020). As seen in the chart, diseases affecting primarily children, such as respiratory infections, diarrheal infections, measles, neonatal disorders, tetanus, malaria, have decreased significantly. The prevalence of diseases affecting older adults, such as ischemic heart disease, diabetes, stroke, lung cancer, has increased and indicates that health care systems need to be prepared to manage an older patient population.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Once burden of disease can be quantified, how do we decide how to tackle it? Enter priority setting to determine how to best allocate resources. A few models have been proposed. In 1971, Abdel Omran posited four stages through which developing countries progress, called the epidemiological transition. The four stages are: age of pestilence and famine; age of receding pandemics; age of degenerative and manmade disease; and age of delayed chronic disease. Developed countries would be categorized in this final stage. However, the stages do not have clear divisions nor is the progression so clear-cut; a country can be in more than one stage simultaneously. For example, developed countries are currently suffering from the Covid pandemic and from chronic diseases. Thus, priority setting based only on the epidemiological transition would provide incomplete aid to countries encountering more than one stage. Another model is the idea of cost-effectiveness. For an intervention to be considered cost-effective, it must cost no more than 3x the per capita health costs. This is difficult to achieve in countries where the per capita health cost is extremely limited and not enough to cover a worthwhile intervention. After recognizing that poor health leads to limited economic development and to address the challenge of figuring out which interventions need investing, the Disease Control Priorities (DCP) Project was created. It aimed to enable countries to choose and prioritize interventions that maximally impact disease burden and that are supported by their health budgets. The latest DCP project promotes equity and advocates for universal health coverage. Both the DCP and GBD projects are ongoing.

Discussion Questions:

•To what extent should developed countries provide economic support to developing countries?

•Which diseases can we anticipate becoming a larger portion of the burden of disease and what can we do to prepare?

Tuberculosis: Global Policy and Impacts of COVID-19 presented by Andrew McAward

Prior to the current COVID-19 pandemic, tuberculosis was the leading cause of death from a single infectious disease. In 2020, 1.5 million people worldwide succumbed to TB, while an additional 10 million were infected with primary TB. However, major global health organizations agree that tuberculosis is both curable and preventable. For this reason, combating tuberculosis continues to remain at the forefront of global health efforts today.
The pathology of the TB is caused by Mycobacterium tuberculosis infection, which classically results in the development of granulomatous lesions in lung tissue. This disease can be latent, acute, or systemic/miliary in nature. Updated treatment protocols continue to recommend using derivations of the “RIPE” therapy regime for up to 6 months. The BCG vaccine is widely used in countries with high TB burden, providing strong protection against tuberculosis meningitis and miliary TB spread in children. However, this vaccine’s lack of effectiveness in adults and contraindication in both pregnant women and the immunocompromised has prompted the WHO to initiate new vaccine development. Additionally, the rising concern of multidrug-resistant TB has increased global efforts to establish new treatment options and a more effective vaccine.

Global health organizations have renewed their ambitions to mitigate the spread of TB. In 2014, the World Health Organization’s “End TB Strategy” set a goal to reduce TB incidence by 80% and death by 90% by 2030. The organization’s intention was to embolden local governmental policies and increase research efforts such as through the development of a new adult candidate TB vaccine, M72/AS01E. Similarly, the United Nations joined the WHO’s response by including the elimination of the tuberculosis epidemic on a list of 17 Sustainable Development Goals (SDGs) to be achieved by the year 2030. Despite these efforts, the progress made in battling TB has been halted by COVID-19. New cases of tuberculosis markedly fell in 2020 due to lack of access to diagnostic services, while global deaths increased for the first time in over a decade. The current COVID pandemic has also worsened prognostic outcomes of patients currently undergoing treatment for tuberculosis. Prior successes of global TB health policy, such as maintaining steady drug supply chain or providing healthcare personnel to assist with direct observation drug therapy, have been disrupted due to the economic and social implications of the current pandemic.
Since 2000, over 66 million lives worldwide have been saved through the diagnosis and successful treatment of tuberculosis. Despite dramatic setbacks caused by COVID-19, the global health community should remain optimistic about the long-term mitigation of this disease.

Discussion Questions:

• How can global health policies help to overcome the challenges caused by COVID-19 in the diagnosis and treatment of TB?

• How can healthcare professionals continue to further the progress made against TB burden in their own communities?

Journal Article: Five insights from the Global Burden of Disease Study 2019 Presented by Rachael Kantor

1. Double Down on Catch-up Development
Improvements in SDI have increased universally at an exponential rate since the 1950s. Originally (and predictably) we saw high SDI countries developing at a much faster rate than low SDI countries BUT since the start of the millennium counties of lower SDIs have been progressing at a rate much faster than those of high SDI statuses showing catch-up development. To close the gap, we must “double down” by increasing economic growth, expanding access to education, and improving the status of women in lower SDI countries. **Socio-demographic Index (SDI) is a measure used in the GBD to identify where a geographic area sits on the spectrum of development.
2. The Minimum Development Goal Health Agenda HAS been working
It’s no secret that since the early 2000s the global health community has focused heavily on decreasing mother and child mortality and decreasing the burden of communicable diseases (specifically TB, HIV, and malaria). The good new is these efforts have been incredibly successful BUT we owe it to ourselves to pay close attention to non-communicable disease (NCD) trends. Population growth and aging have led to a steady increased in NCDs.
3.Health Systems need to be more agile to adapt to the rapid shifts to NCDs and disabilities
As health profiles and SDI rankings change, universal health coverage must adapt to meet current health needs. This means increased focus on NCD coverage and greater attention to disorders causing functional health loss (MSK, substance abuse, mental health, etc.) to reduce the massive policy gap.
4. Public health is failing to address the increase in crucial global health risk factors
As global SDI has increased, many risk factors have seen a sharp decline. However, risk factors including High SBP, FBG, and BMI, as well as alcohol and drug use have increased alarmingly by > 0.5% a year.
5. Social, fiscal, and geopolitical challenges of inverted population pyramids
The GBD has estimated that by 2100 there will be over 150 countries whose death rate exceeds its birth rate; this compared to 34 countries in 2019. Many country populations will decrease—resulting in tremendous controversy regarding workforce maintenance, the ongoing immigration debate, and fertility incentivization2.

Discussion Questions:

•Many editorials/opinions call the neglect of chronic illness, and the exponential rise of preventable risk factors the “perfect storm” to fuel the COVID-19 pandemic. What sort of policies (concrete or abstract) should be put into place to take urgent action against this “failure of public health,” making countries more resilient to future pandemic threats?

•The authors of this study have concluded that exposure to/smoking tobacco has fallen 1-2% a year worldwide since 2010 due to the major efforts to implement international tobacco control policies rather than providing information to consumers about the harms of tobacco. However, the rate of exposure to other risk factors are increasing by more than 0.5% a year. Given the successes/failures of the efforts to decrease tobacco exposure, what place does government and international legislation have in the efforts to reduce these other risk factor exposures?

~This second discussion question provided an excellent conversation on the importance of individual autonomy and governmental policy influence, as well as those factors, including social determinants of health that limit both the individual and a government’s ability to take viable action to reduce risk factor exposure.

Wrap up!

Thank you to our authors and presenters!

Denise Manfrini, MS4

University of Florida

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Rachael Kantor, MS4

The Medical School for International Health at Ben Gurion University

Sources and Further Reading:

Mukherjee, J. (2017). Chapter 4: Global Health and the Global Burden of Disease. In An Introduction to Global Health Delivery (pp. 89–105). book, Oxford University Press.
GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.
Global Health CEA registry database with publications from different countries about cost-saving interventions – https://cevr.shinyapps.io/LeagueTables/
Kant, Surya, and Richa Tyagi. “The Impact of Covid-19 on Tuberculosis: Challenges and Opportunities.” Therapeutic Advances in Infectious Disease, vol. 8, 9 June 2021, p. 204993612110169., https://doi.org/10.1177/20499361211016973.
Kirby, Tony. “Global Tuberculosis Progress Reversed by COVID-19 Pandemic.” The Lancet Respiratory Medicine, 2 Nov. 2021, https://doi.org/10.1016/s2213-2600(21)00496-3.
Roy, A., et al. “Effect of BCG Vaccination against Mycobacterium Tuberculosis Infection in Children: Systematic Review and Meta-Analysis.” BMJ, vol. 349, no. aug04 5, 2014, https://doi.org/10.1136/bmj.g4643.
“Tuberculosis (TB).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Oct. 2021, https://www.cdc.gov/tb/default.htm.
“Tuberculosis (TB).” World Health Organization, World Health Organization, 14 Oct. 2021, https://www.who.int/news-room/fact-sheets/detail/tuberculosis.
GBD 2019 Viewpoint Collaborators. Five insights from the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1135-1159. doi: 10.1016/S0140-6736(20)31404-5. PMID: 33069324; PMCID: PMC7116361.
Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396: 1160-1203

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You have a new patient!

What do you need to know?

Epidemiology and Importance

Pathophysiology

Medical History

Algorithmic Approach in Seizure History [2]

Physical Examination

Alternative Diagnoses

Acing Diagnostic Testing

Risk Stratification

Management

First-line therapy [2, 28, 29]

Second-line therapy [2, 28, 29]

Third-line therapy [2, 28, 29]

Special Patient Groups

When To Admit This Patient

Revisiting Your Patient

Authors

Rand Redwan Al Sari

Imad Khojah

Listen to the chapter

References

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

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Introduction

You have a new patient!

What do you need to know?

Seizure Presentation and Classification

Medical History

Key Components of History Taking

Physical Examination

Alternative Diagnoses

Acing Diagnostic Testing

Risk Stratification

Management

Midazolam (1st Line Agent – Benzodiazepine)

Diazepam (1st Line Agent – Benzodiazepine)

Levetiracetam (2nd Line Agent)

Phenytoin (2nd Line Agent)

Fosphenytoin (2nd Line Agent)

Valproate (2nd Line Agent)

Propofol (3rd Line Agent)

Phenobarbital (3rd Line Agent)

Midazolam (for 3rd Line use) (3rd Line Agent)

Special Patient Groups

Pediatrics

Geriatrics

Pregnant Patients

When To Admit This Patient

Revisiting Your Patient

Authors

Ardi Knobel Mendoza

Danielle Charles-Chauvet

Erik J. Blutinger

Listen to the chapter

References

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

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The Economic Impact of Ebolavirus in West Africa: A Burden the Size of Iceland by Andrew L. Mariotti

Chapter 4: Global Health and the Global Burden of Disease by Kelsey Yenney

Wrap up!

Thank you to our authors and presenters!

Andrew L. Mariotti, MS3

Kelsey Yenney, MS3

Blog Editorial Team

Halley Alberts, MD

Jeff Downen, PGY2

Mohamed Hussein, MBBCh

Resources

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Telemedicine in Low-Resource Settings by Rachel Patel

The Roots of Global Health Inequity by Grace Bunemann

Wrap up!

Thank you to our authors and presenters!

Rachel Patel, MS4