Although they may not appear to be as physically injurious as convulsive seizures, non-convulsive seizures can significantly impact the neurological outcomes and overall prognosis of patients in critical care settings. Especially in the case of status epilepticus, delayed treatment can lead to a phenomenon known as pharmacoresistance, in which the effectiveness of antiseizure medications diminishes over time due to neurobiological changes that alter drug targets (e.g., reduced surface expression of postsynaptic GABA-A receptors) and drug transport mechanisms (e.g., increased expression of drug efflux transporters) to enable self-sustaining ictal rhythms.5,6 This underscores the importance of vigilance and integrating clinical findings with advanced diagnostic tools like EEG to improve diagnostic accuracy for seizures and refine the management of critically ill patients to ensure comprehensive neurological care.7
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ACEP Now: July 2026EEG Monitoring in Managing Seizures
Several studies demonstrated the importance of EEG monitoring in the management of seizures.8-11 Although continuous EEG monitoring would be the gold standard for diagnosing and managing non-convulsive seizures, it is either unavailable or delayed at many centers, and it is rarely performed in the ED. This is because conventional EEG requires a large machine, a qualified technologist, and a significant amount of time for set up, and the output data must be reviewed and interpreted by a neurologist. Some institutions have the capability to perform real-time EEG monitoring and interpretation by a neurologist in the ED. Other devices demonstrated potential use as an alternative to traditional EEG monitoring.
For example, other modes of EEG monitoring may be used in the operative setting, including bispectral index monitoring (BIS), SEDline device, and others to monitor depth of sedation.12 Several commercially available point-of-care EEG devices exist.13 A point-of-care EEG system has been developed to provide real-time EEG data.14 Preliminary data suggest that among 157 adult patients, point-of-care EEG enabled acquisition of EEG data within 90 minutes of ED arrival, identified epileptiform activity in 36 percent of patients, and impacted treatment decisions.15 The potential advantage of point-of-care EEG is rapid diagnosis, although focal seizures may be missed due to fewer electrodes. Future research is needed to determine the sensitivity and specificity of this device, particularly in the ED environment, where patients might have taken medications or recreational drugs, or might have received sedative or antiepileptic medications.
Diagnostic studies useful in determining the etiology may include POC glucose, serum electrolytes, and complete blood count. Other considerations dependent on the clinical setting and history may include CT scan, MRI, or lumbar puncture.
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One Response to “Point-of-Care EEG Is Not Ready for Prime Time”
August 2, 2026
Rick Kozak, MDDear Dr Marco,
I read your response from the ACEP Now Editorial Team entitled Point -of-Care EEG: Not Ready for Prime Time. Your comments appear to support the use of POC-EEG in the emergency department. Other than the future directions and questions to be answered, which are issues actively being studied and written about , each of your paragraphs supports emergency physicians utilization of POC-EEG. Dr Smart is missing the point that a brain can be seizing while motor clues are absent and therefore we need to educate emergency physicians on the use of devices to allow appropriate treatment quickly. The definition of non-convulsive status epilepticus definition is debated by epileptologists but also defined by them “in concesus”. Her last sentence then describes what the POC-EEG is being used for in facilities that have it. I might be overstepping, but does your final concern about unintended consequences suggest that POC-EEG might delay treatments like airway protection? I doubt that an emergency physician would do that. Would you hypothesize that an emergency physician would under-medicate patients who need anti-seizure medications(ASMs) if the EEG reads “zero seizure burden”? What I see at facilities that utilize POC-EEG are emergency physicians quickly giving the high dose benzodiazepines knowing it will lead to intubation and adding second line ASMs quickly when they are responding to device feedback. I also see patients who are afforded more time to wake up and subsequently go home when there prolonged post ictal period is monitored and ASM escalation is avoided.
I am collaborating to write research protocols for investigator-initiated research and believe that funding should be available from federal agencies to untie conflicts of interest.
Respectfully,