Emergency physicians are accustomed to making high-stakes decisions in diagnostic gray zones. Few scenarios are more frustrating than the persistently unresponsive, post-cardiac arrest, or otherwise altered patient in whom nonconvulsive seizure remains on the differential, yet timely electroencephalography (EEG) is unavailable.

For many hospitals, the traditional answer has been to transfer. If diagnostic EEG cannot be obtained locally, the patient must be sent to a tertiary referral center for neurologic evaluation and potentially continuous EEG monitoring. On paper, that sounds reasonable. In practice, it often exposes a deeper problem within the health care system.

In my experience at my own hospital, even when patients were transferred from emergency department (ED) to ED for urgent neurologic evaluation, EEG was not always performed in a timely fashion, and in some cases, was not performed at all. That revealed an uncomfortable truth: transfer did not reliably deliver the answer it was meant to provide. Instead, it added delay, transport burden, and family disruption while the core clinical question remained unresolved. In many cases, patients were transferred not because treatment could not be provided locally, but because the diagnosis could not be made locally. Once the diagnosis is established or excluded, treatment can often proceed without transfer.

That is why point-of-care EEG is coming to the ED. It is not arriving simply because the technology has become more plentiful and interesting, but because emergency medicine has a real diagnostic access problem that existing pathways do not consistently solve.

At my hospital, we became early adopters because we repeatedly encountered patients for whom earlier EEG access could change management, yet the traditional pathway depended on transfer for diagnosis. Point-of-care EEG was not just a new device. It was a practical response to a frontline problem in emergency care.

Equipment Upgrades Advance EEG Usage

Several developments made this shift possible. EEG systems have become easier to apply, hardware has become smaller and more portable, and algorithmic analysis has improved. Telemetry has further changed the equation, allowing rapid EEG acquisition locally and enabling it to be reviewed remotely by epileptologists. These advances have made it realistic to bring EEG closer to the immediacy and pace of emergency medicine.

As point-of-care EEG enters emergency care, two practical models have emerged: a limited montage headband-style system for rapid bedside assessment and a full montage cap-based system that more closely approximates a traditional EEG. That distinction matters because they do not answer the same question in the same way.

A useful analogy is ECG. A limited montage headband EEG is not the same as a full montage study, just as a monitor strip is not the same as a 12-lead ECG. It may be fast, simple, and helpful when the immediate question is whether obvious electrographic seizure activity is present. But because it does not mirror the more complete framework most familiar to epileptologists, it will often still prompt a traditional full-montage EEG. In practical terms, it may serve as a triage or screening tool rather than the final diagnostic endpoint.

A full montage cap-based system offers a different value proposition. By providing a complete EEG that nears equivalency to a conventional study, it may detect a broader range of abnormalities and provide greater diagnostic confidence. Operationally, a limited montage system may still fit into a need-to-transfer pathway, while a full montage system is more likely to function as a transfer-sparing diagnostic pathway because it may answer key questions locally.

The central issue is not simply whether EEG can be performed quickly, but whether the study obtained in the ED is sufficient to answer the question that drove concern in the first place. In many cases, the problem is not that antiseizure medications, airway management, or critical care support are unavailable locally. The problem is that diagnostic certainty is not immediately available. Once the diagnosis is established, treatment can proceed in a community hospital like mine. Point-of-care EEG changes the location of that diagnosis and, in doing so, changes downstream transfer decisions.

Putting EEG Technology to Use at Bedside

The most immediate application of this technology is the diagnosis of nonconvulsive seizures and nonconvulsive status epilepticus. These patients are already in our EDs: the intubated patient who is not waking up; the postictal patient who remains altered longer than expected; or the patient with unexplained encephalopathy, subtle abnormal movements, or persistent concern for seizure without visible convulsive activity. In these cases, physical examination and routine monitoring are often not enough. Earlier EEG shortens the period of uncertainty and allows treatment to be escalated, redirected, or withheld based on actual cerebral data rather than inference.

Earlier diagnosis matters, especially when the seizure is not clinically obvious. When electrographic seizure activity continues unrecognized, the brain remains under physiologic stress longer and becomes more difficult to control. Point-of-care EEG therefore brings the answer closer to the moment when treatment decisions matter most.

A second major area of relevance is the post-cardiac arrest patient. These patients often remain unresponsive after return of spontaneous circulation, and the differential includes ongoing seizure activity, diffuse cerebral injury, medication effect, and delayed recovery. EEG is now important in this population not only for seizure detection, but also as part of structured neurologic assessment, and it has been incorporated into updated American Heart Association guidance for post-cardiac arrest management. For emergency and ICU physicians, that means EEG is no longer something that belongs later in the ICU course. It is becoming part of the early evaluation in post-arrest patients whose neurologic status remains uncertain.

A third emerging area is stroke and focal cerebral dysfunction. Stroke will remain an imaging-driven pathway, but cerebral ischemia produces electrophysiologic changes. There is increasing interest in whether portable EEG can help identify localized decreases in cerebral activity, support early triage, or complement evaluation in the field and ED. This remains an evolving area rather than standard practice, but points toward a broader future role for EEG in frontline neurologic care.

Perhaps the most underappreciated benefit of point-of-care EEG is its ability to keep appropriate patients close to home. Community hospitals do not need to become tertiary neuroscience centers, but they do need tools that allow them to answer urgent neurologic questions locally when possible. If EEG can be obtained promptly in the ED, interpreted with sufficient confidence, and paired with specialists’ remote review, some patients who once would have been transferred for diagnosis alone may remain in their community hospital for treatment. That reduces system burden and preserves higher-level referral resources for the patients who truly need them.

Point-of-care EEG should not be viewed as a replacement for conventional EEG, and the available systems are not interchangeable. But the direction is clear: EEG is moving toward the bedside because emergency care increasingly needs it there. The old model often forced transfer simply to obtain a diagnosis, and even then, the answer was not always delivered quickly. Point-of-care EEG changes that equation by allowing the ED to ask an urgent neurologic question sooner, answer it closer to home, and reserve transfer for the patients who truly need higher-level care.

Author Disclaimer: We use a Zeto system at our hospital and, as an early adopter of their technology, have a professional relationship and have helped them further develop the product to better fit with our specific needs. Zeto did fly me out to a critical care conference in Chicago earlier this year to talk about our experience with the product in the ER, however, I did not receive any income for doing so.

Dr. Syrett is chief medical officer and emergency physician at the Auburn Community Hospital in Auburn, N.Y.