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New toxins are constantly emerging within society. We review common toxins that cause seizure, their mechanisms, associated toxidromes, and treatments. Stimulants, cholinergic agents, gamma-aminobutyric acid (GABA) antagonists, glutamate agonists, histamine and adenosine antagonists, and withdrawal states are highlighted. Understanding current mechanisms for common toxin-induced seizures can promote understanding of future toxins and predicting if seizure may occur as a result of toxicity., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Functional or psychogenic seizures have proved a diagnostic and therapeutic challenge for centuries. Functional seizures can look and feel similar to epileptic seizures but are instead a common and highly disabling form of functional neurologic disorder, or conversion disorder. Consistent with the biopsychosocial model of mental illness, functional seizures are caused by biological, psychological, and social factors unrelated to epileptic discharges. People with functional seizures do not consciously fake their symptoms. Functional seizures can be differentiated from epileptic seizures through the clinical history, features of the seizures themselves, and electroencephalography findings. Psychotherapy is effective in treating functional seizures., Competing Interests: Disclosure No disclosures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The diagnosis and management of neurologic conditions are more complex at the extremes of age than in the average adult. In the pediatric population, neurologic emergencies are somewhat rare and some may require emergent consultation. In older adults, geriatric physiologic changes with increased comorbidities leads to atypical presentations and worsened outcomes. The unique considerations regarding emergency department presentation and management of stroke and altered mental status in both age groups is discussed, in addition to seizures and intracranial hemorrhage in pediatrics, and Parkinson's disease and meningitis in the geriatric population., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims., (Copyright © 2020 Elsevier Inc. All rights reserved.)

As a group, neurologic conditions represent a substantial portion of emergency department (ED) visits. Cerebrovascular disease, headache, vertigo and seizures are all common reasons for patients to seek care in the ED. Patients being treated for each of these conditions are amenable to care in an ED observation unit (EDOU) if they require further diagnostic or therapeutic interventions beyond their ED stay. EDOUs are the ideal setting for patients who require advanced imaging such as MRIs, frequent neuro checks or specialist consultation in order to determine if they require admission or can be discharged home., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Neurologic diseases are a major cause of death and disability in elderly patients. Due to the physiologic changes and increased comorbidities that occur as people age, neurologic diseases are more common in geriatric patients and a major cause of death and disability in this population. This article discusses the elderly patient presenting to the emergency department with acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, chronic subdural hematoma, traumatic brain injury, seizures, and central nervous system infections. This article reviews the subtle presentations, difficult workups, and complicated treatment decisions as they pertain to our older patients.", (Copyright © 2016 Elsevier Inc. All rights reserved.)

Seizures are a commonly encountered condition within the emergency department and, because of this, can engender complacency on the part of the physicians and staff. Unfortunately, there is significant associated morbidity and mortality with seizures, and they should never be regarded as routine. This point is particularly important with respect to seizures in pediatric patients. The aim of this review is to provide a current view of the various issues that make pediatric seizures unique and to help elucidate emergent evaluation and management strategies., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Neurologic symptoms commonly occur in oncology patients, and in some cases they may be the presenting symptom of malignancy. Cancer-related neurologic syndromes are rarely pathognomonic and must be differentiated from other benign or serious conditions. This article reviews common neuro-oncologic syndromes that may lead to urgent evaluation in the emergency department, including cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic neurologic syndromes.

Although there are a variety of neurologic disease processes that the emergency physician should be aware of the most common of these include seizures, closed head injury, headache, and syncope. When one is evaluating a patient who has had a seizure, differentiating between febrile seizures, afebrile seizures, and SE helps to determine the extent of the work-up. Febrile seizures are typically benign, although a diagnosis of meningitis must not be missed. Educating parents regarding the likelihood of future seizures, and precautions to be taken should a subsequent seizure be witnessed, is important. The etiology of a first-time afebrile seizure varies with the patient's age at presentation, and this age-specific differential drives the diagnostic work-up. A follow-up EEG is often indicated, and imaging studies can appropriate on a nonurgent basis. Appropriate management of SE requires a paradigm of escalating pharmacologic therapy, and early consideration of transport for pediatric intensive care services if the seizure cannot be controlled with conventional three-tiered therapy. Closed head injury frequently is seen in the pediatric emergency care setting. The absence of specific clinical criteria to guide the need for imaging makes management of these children more difficult. A thorough history and physical examination is important to uncover risk factors that prompt emergent imaging. Headaches are best approached by assessing the temporal course, associated symptoms, and the presence of persistent neurologic signs. Most patients ultimately are diagnosed with either a tension or migraine headache; however, in those patients with a chronic progressive headache course, an intracranial process must be addressed and pursued with appropriate imaging. Syncope has multiple causes but can generally be categorized as autonomic, cardiac, or noncardiac. Although vasovagal syncope is the most common cause of syncope, vigilance is required to identify those patients with a potentially fatal arrhythmia or with heart disease that predisposes to hypoperfusion. As such, all patients who present with syncope should have an ECG. Additional work-up studies are guided by the results of individual history and physical examination.

Statistics tell us that as many as 1 in 20 members of the population will suffer a seizure at some point in their lifetime, a figure which becomes even more likely if one lives to the age of 80. Thus, a careful evidence based approach to the patient with seizure is immensely useful to the emergency physician. The authors evaluate current studies on the subject, discuss seizures as they relate to specific patient groups, and, ultimately, make recommendations on this important subject.

A pediatric focus in the emergency department requires an understanding of age-specific parameters of assessment and management. Differential considerations are unique in the pediatric patient reflecting both congenital and acquired conditions. Respiratory problems, meningitis, seizures, and child abuse require careful assessment and aggressive intervention. When approaching the ill child, attention must be directed toward reducing anxiety and pain in the patient.

Seizures in pregnancy may risk the health of both mother and fetus. Epileptic women should ideally plan pregnancies after counseling by their primary care givers. New-onset seizures and any increase in seizure frequency or severity should be promptly evaluated. Eclampsia and status epilepticus represent life-threatening conditions that demand urgent multidisciplinary management.

Psychogenic seizures are nonepileptic events that are varied in their clinical presentations. These events can be psychiatric or physiologic in their origin and can occur concomitantly in patients with epileptic seizure disorders. The diagnosis often requires laboratory and electrophysiologic investigation; however, historical, clinical, and laboratory findings can aid in making the diagnosis.

Seizure is an omnimous sign when it occurs in relation to drugs or toxins. Knowledge of those drugs or toxins that have a predilection to cause seizures may prove invaluable when one is treating such a patient. Aggressive treatment with the appropriate therapy may have a significant impact on outcome. As seen from this article, many drugs and toxins are associated with seizures. Fortunately, the majority of these seizures can be managed with supportive care, using the standard anticonvulsant drugs. Management of the seizure in a few drugs and toxins requires additional intervention. It is the addition of these specific treatment modalities that may prove to be lifesaving despite drug- or toxin-induced seizures.

Epilepsy is a chronic disorder characterized by recurrent unprovoked epileptic seizures. Not all epileptic seizures indicate the existence of an epileptic disorder; many represent a natural response of the normal brain to transient noxious insults that are not likely to be repeated (reactive seizures). Not only is it important to distinguish conditions associated with these relatively benign epileptic events from epilepsy, but also it is important to recognize the many types of epileptic seizures and many types of epilepsy, reflecting different underlying anatomic and pathophysiologic substrates, which determine therapy and prognosis. Acute care for an epileptic seizure, therefore, includes search for an underlying treatable cause and protection against recurrence, if necessary. Neurologic consultation in the emergency department can help avoid unnecessary diagnostic procedures and treatments, particularly in patients with reactive seizures and established epileptic disorders. Communication with the patient's continuing care physician is an essential part of the emergency department management plan.

Posttraumatic epilepsy is one of the most clinically disturbing and, to date, difficult predictive factors associated with head trauma. The risk of developing seizures after head trauma depends on several factors. This article explores the mechanisms and biochemical effects of brain injury, their relationship to developing seizures, antiepileptic prophylaxis, and neuroprotective pharmacologic therapy.

The patient with an apparent first seizure presents a diagnostic and therapeutic challenge to the emergency department or primary care physician. Proper management of these patients requires a systematic diagnostic evaluation and assessment of the risks and benefits of treatment. Such an assessment requires that the following issues be addressed: Was the attack truly a seizure? Was this seizure truly the first seizure for this patient? Why did the seizure occur? Was the seizure a symptom of an acute neurologic or medical illness, a remote neurologic injury, or did the attack occur without evident cause? How extensive (and expensive) should the diagnostic evaluation be? If a cause for the seizure is identified, is direct therapy available or necessary? What is the likelihood of a recurrent attack? Will treatment with anticonvulsant drugs significantly reduce the risk of subsequent seizures? What are the risks of anticonvulsant drug treatment? Is anticonvulsant drug therapy appropriate for this patient at this time? It should be clear from the preceding discussion that definitive answers to such questions are not possible. The clinical data are always incomplete and uncertain and sometimes erroneous. Considerable clinical judgment is always needed. Nonetheless, we can hope that conscientious, systematic assessment will lead to the best possible treatment for each of our patients.

A practical approach to the emergency management of seizures and seizure-like nonepileptic states in childhood has been presented. The management of tonic-clonic, absence, partial complex, and focal status epilepticus was discussed. Management of the child who has had a recent episode but does not present with a seizure was outlined, with particular attention to relevant history taking, general and neurologic examinations, laboratory tests, and treatment options. Finally, seizure-like nonepileptic disorders were reviewed and differential diagnostic points highlighted.