Non-1st seizure was less severe than 1st seizure with non-urgent level among suspected seizures transferred by ambulance

PLOS ONE RESEARCH ARTICLE Non-1st seizure was less severe than 1st seizure with non-urgent level among suspected seizures transferred by ambulance Yotaro Asano1, Ayataka Fujimoto ID2*, Keisuke Hatano ID2, Keishiro Sato2, Takahiro Atsumi3, Hideo Enoki2, Tohru Okanishi4 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Hamamatsu University School of Medicine, Shizuoka, Japan, 2 Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan, 3 Department of Emergency Medicine, Seirei Hamamatsu General Hospital, Shizuoka, Japan, 4 Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan * Abstract OPEN ACCESS Citation: Asano Y, Fujimoto A, Hatano K, Sato K, Atsumi T, Enoki H, et al. (2023) Non-1st seizure was less severe than 1st seizure with non-urgent level among suspected seizures transferred by ambulance. PLoS ONE 18(8): e0290783. https:// doi.org/10.1371/journal.pone.0290783 Editor: Ryan G. Wagner, University of the Witwatersrand Johannesburg, SOUTH AFRICA Background To prioritize emergency medical calls for ambulance transport for patients with suspected seizures, information about whether the event is their 1st or non-1st seizure is important. However, little is known about the difference between 1st and non-1st seizures in terms of severity. We hypothesized that patients transferred multiple times (�2 times) would represent a milder scenario than patients on their first transfer. The purpose of this study was to compare patients with suspected seizures on 1st transfer by ambulance and patients who had been transferred �2 times. Received: December 16, 2022 Accepted: August 15, 2023 Published: August 29, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0290783 Copyright: © 2023 Asano et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the manuscript. Funding: The authors received no specific funding for this work. Methods We statistically compared severity of suspected seizures between two groups of patients with suspected seizures transferred between December 2014 and November 2019 (before the coronavirus disease 2019 pandemic) to our facility by ambulance for either the first time (1st Group) or at least the second time (Non-1st Group). Severity categories were defined as: Level 1 = life-threatening; Level 2 = emergent, needing admission to the intensive care unit; Level 3 = urgent, needing admission to a hospital general ward; Level 4 = less urgent, needing intervention but not hospitalization; and Level 5 = non-urgent, not needing intervention. Results Among 5996 patients with suspected seizures conveyed to the emergency department by ambulance a total of 14,263 times during the study period, 1222 times (8.6%) and 636 patients (11%) met the criteria. Severity grade of suspected seizures ranged from 1 to 5 (median, 4; interquartile range, 3–4) for the 1st Group and from 1 to 5 (median, 5; interquartile range, 4–5) for the Non-1st Group. Most severe grade ranged from 1 to 5 (median, 4; interquartile range, 4–5) for the Non-1st Group. Severity grade differed significantly between PLOS ONE | https://doi.org/10.1371/journal.pone.0290783 August 29, 2023 1 / 12 PLOS ONE Competing interests: The authors have declared that no competing interests exist. Lower severity with non-1st ambulance transfer groups (p < 0.001, Mann–Whitney U-test). Uni- and multivariate logistic regression tests also suggested a significant difference (p < 0.001) in severity grades. Conclusion In direct comparisons, grade of suspected seizure severity was lower in the Non-1st Group than in the 1st Group. 1. Introduction Many guidelines and instructive movies do not include an emergency medical call as part of basic first aid in cases of seizure. For example, the websites of the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/epilepsy/about/first-aid.htm), International League Against Epilepsy ILAE) (https://www.ilae.org/patient-care/for-persons-with-epilepsy-andcaregivers/first-aid-during-a-seizure), Epilepsy Action Australia (https://www.epilepsy.org.au/ about-epilepsy/first-aid/), Japan Division, and International Bureau for Epilepsy (https://www. jea-net.jp/epilepsy/spasm) do not recommend an emergency medical call, but basic first aid is the first priority. The Swiss League Against Epilepsy (https://www.youtube.com/watch?v=XcWmksrEBk), the seizure first aid poster of the Epilepsy Foundation (https://www.epilepsy. com/recognition/first-aid-resources) and Epilepsy Action Australia all provide educational instructions about first aid for epileptic seizures. According to those posters and movies, basic first aid should be provided as follows: 1) stay with the person until they are awake and alert after the seizure [time the seizure, remain calm, and check for medical identification (ID)]; 2) keep the person safe (move or guide them away from harm); 3) turn the person onto their side and then, finally, consider calling an ambulance. According to these guidelines, a patient showing: 1) seizure lasting <5 min; 2) self-limited seizures; and 3) habitual stereotypical seizures, not the first seizure, in most cases only needs basic first aid, not ambulance transfer or a visit to the emergency department (ED) [1–3]. However, inappropriate or unnecessary ambulance calls are a problem in the real world [4, 5] and have long been discussed [1, 6]. This issue remains topical [7, 8]. The reason for timing seizures is that convulsive seizures lasting >5 min can be considered status epilepticus (SE) [9], in which the risk of neuronal injury or neuronal death is greatly increased [9]. The reason for noting whether a seizure event represents the first seizure is that an acute symptomatic seizure (ASS) might be caused by an irreversible condition, such as stroke, head trauma, or infection [10–12]. Medical IDs such as a bracelet or tag might therefore help decide whether an event is the first seizure or a habitual stereotypical epileptic seizure in a patient with established epilepsy. When considering an ambulance call, the guideline can be simplified into: 1) does the seizure event represent SE or not; 2) does the seizure event represent a first or non-first seizure; and 3) does the individual have concomitant symptoms such as physical injuries, fever, or non-stereotypical seizures. The presence of SE and/or concomitant symptoms can understandably be considered to wa (...truncated)