A 27-year-old woman lies on the ED stretcher, eyelids squeezed shut as her arms rhythmically tremble against the sheet. Her sister says the episode has lasted nearly 12 minutes, but the patient’s breathing remains regular and she briefly turns her head when spoken to. The monitor shows a sinus rhythm and oxygen saturation of 99%; no one has yet decided whether this is ongoing status epilepticus or something else.

— What’s your move? Read on.

Before you read
  • When is it dangerous to withhold treatment for possible epileptic status?
  • What is the ED’s therapeutic role after the event stops?

When to Think of It

Consider functional seizures with prolonged or fluctuating convulsive-appearing events, asynchronous or side-to-side movements, tightly closed eyes, preserved awareness or recall, rapid changes in motor pattern, ictal crying, and events occurring in emotionally or socially charged settings. These are clues, not standalone diagnostic proof. Video-EEG capturing a typical event without an epileptiform correlate is the diagnostic standard.

Sick or Not Sick

The key call is “Could this still be epileptic status or an immediately dangerous mimic?” Check airway, ventilation, glucose, trauma, pregnancy, toxicologic context, focal neurologic deficit, and recovery pattern before labeling the event functional.

The First Fifteen Minutes

  • Ongoing convulsive activity with impaired awareness and no reliable way to exclude status → midazolam 10 mg IM once (or 0.2 mg/kg IV, maximum 10 mg, if IV access); it rapidly suppresses dangerous epileptic activity while definitive assessment continues. Check a dosing reference if using nonstandard weight-based protocols.
  • If hypoglycemia is confirmed → dextrose 25 g IV (50 mL of D50) in an adult with severe hypoglycemia; glucose restores substrate for neuronal function. Use dextrose 10% 125–250 mL IV when peripheral extravasation risk or local protocol favors D10.
  • If the patient has a pulse but cannot protect the airway, has persistent hypoxemia, or has severe agitation after sedative treatment → airway positioning, suction, oxygen, and ventilation; do not administer additional sedatives solely to stop functional movements.
  • Once epileptic status and medical instability are unlikely → no antiseizure medication; calmly reduce stimulation, protect from injury, and avoid restraint unless necessary for immediate safety.

Definitive Care & Disposition

Obtain collateral history, review prior video-EEG and antiseizure medications, and involve neurology. A typical event should be captured on video-EEG when the diagnosis remains uncertain. Explain that the events are real, involuntary, and treatable; avoid “faking” language. Admit for persistent altered mental status, injury, pregnancy-related concern, recurrent uncertain events, suicidality, or inability to establish safe follow-up. Stable patients may be discharged with neurology and mental-health follow-up, a safety plan, and clear return precautions.

How This One Kills

The dangerous error is repeated benzodiazepine escalation for a prolonged functional event, producing respiratory failure and intubation while the underlying diagnosis remains unaddressed.
The Differential — What Else Looks Like This
  • Generalized convulsive status epilepticus — stereotyped tonic–clonic evolution with impaired awareness and postictal recovery; delaying therapy risks neuronal injury.
  • Syncope with convulsive movements — brief episode linked to standing or arrhythmia, rapid reorientation; missing cardiac syncope risks sudden death.
  • Hypoglycemia — low bedside glucose during symptoms; untreated neuroglycopenia can progress to coma.
  • Movement disorder or rigors — preserved interaction and stimulus-linked movements; mislabeling may lead to unnecessary antiseizure treatment.

The Second-Day Story

Older adults, patients with intellectual disability, and patients already receiving sedatives may have subtle shaking, staring, intermittent unresponsiveness, or unexplained post-event behavior rather than dramatic movements. Conversely, functional events may coexist with epilepsy, so a prior diagnosis of functional seizures does not make every future event functional. Repeated semiology, collateral video, glucose, medication review, and recovery trajectory are more reliable than a single visual impression.
Back to Our Patient
Back to our 27-year-old woman: she is oxygenating normally, has rhythmic but changing movements, tightly closed eyes, no lateral tongue injury, and briefly responds to her sister; bedside glucose is normal and there is no trauma. Because epileptic status cannot initially be excluded, the team protects her airway and obtains IV access, but does not repeatedly escalate medication when her breathing and examination remain stable; the movements stop with calm reassurance, and she rapidly recalls the event. Neurology reviews a prior video-EEG showing the same semiology without an epileptiform correlate, supporting functional seizures. After assessment for suicidality and a safe follow-up plan, she is discharged with neurology and psychological therapy referral.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 27-year-old woman with recurrent prolonged shaking episodes, presenting after approximately 12 minutes of bilateral arm trembling. Her sister reports preserved regular breathing and intermittent response, with no preceding fever, trauma, substance exposure, or missed antiseizure medication. She is now alert, oxygenating normally, and has no focal deficit, lateral tongue trauma, or significant injury; the movements were asynchronous with tightly closed eyelids and changed pattern several times. Glucose and ECG are normal. I’m concerned for a functional seizure, but I initially treated the event as possible status until dangerous causes were excluded; she is now stable without further sedative treatment, and I recommend neurology review, confirmation against prior video-EEG, safety assessment, and outpatient follow-up.”

Study Directive

  • Review three patient-recorded videos and list the semiologic clues for functional versus epileptic events.
  • Practice a 30-second nonstigmatizing explanation: “The events are real, involuntary, and arise from altered brain functioning rather than epileptic electrical discharges.”
  • Memorize the adult benzodiazepine status dose and your institution’s escalation pathway.
  • Write a discharge checklist including injury precautions, suicidality screening, neurology follow-up, and return precautions.

Recent Literature