There are an estimated 150,000 new cases of epilepsy per year in the United States, with prevalence rates of 7–8 per 1,000 persons. These data, combined with the large number of patients who have seizures from nonepileptic causes, indicate that seizure occurrence is relatively frequent and can result from diverse causes. Although many patients who have a seizure do not need emergency department (ED) care, some present to the ED critically ill and require immediate, definitive management. Advances in the understanding of seizure types and use of new antiseizure medications have enhanced the emergency physician’s ability to diagnose the cause of a patient’s seizures accurately and to treat both the underlying abnormality and the seizures in a rational and systematic fashion.

Status epilepticus (SE) is a neurological emergency defined as a continuous seizure or cluster of seizures lasting longer than 30 minutes. Because of increased mortality risk, SE is practically defined at 5 minutes. Clinically, SE can be separated into convulsive SE (CSE) or nonconvulsive SE (NCSE). For both diagnoses, the initial treatment of choice is a benzodiazepine, most commonly lorazepam 4 mg IV. Midazolam and diazepam (to a lesser extent) are also appropriate. If the status epilepticus continues, loading doses of fosphenytoin (20 mg/kg), levetiracetam (60 mg/kg), or valproate (40 mg/kg) are the next step in management. Continuation of SE past this point is considered refractory. For CSE, patients are almost always intubated and managed with IV anesthesia. For NCSE, intubation is often not needed at this point, with additional ASMs used instead to sidestep the risk associated with intubation and IV anesthesia. A key factor in guiding SE management is identifying the etiology (i.e., antibiotics for meningitis).Lastly, post cardiac arrest is briefly discussed as it is unfortunately commonly encountered.