clonic seizure is now called bilateral tonic-clonic seizure (previously referred to as a secondarily generalized seizure), to differentiate it from seizures that are generalized from the onset It is important to recognize that generalized seizures with focal manifestations are also considered focal These manifestations may include lateral eye deviation, head tilt, postictal Todd paresis (or paralysis), or psychomotor seizures (also referred to as temporal lobe seizures) Status epilepticus is a form of prolonged seizure This is defined as seizures lasting more than minutes or repetitive seizure activity without recovery of consciousness in between episodes This is an operational definition used to guide therapy While only 25% of pediatric seizures last longer than minutes, the longer a seizure persists, the more difficult it becomes to control If a child is seen in the ED with a reported/witnessed generalized seizure that has resolved, a 30minute cutoff is used to define status, because 30 minutes is when the risk of permanent neuronal injury increases significantly Status epilepticus is the highest form of seizure emergency A postictal (decreased responsiveness) period usually follows a seizure During this time, the patient may be confused, lethargic, fatigued, or irritable; also, headache, vomiting, and muscle soreness may occur In general, the length of the postictal period is proportional to the length of the seizure For brief seizures, there may be few or no postictal symptoms Transient focal deficits (e.g., Todd paralysis) may occur during the postictal period, but one must first rule out a focal central nervous system (CNS) deficit PATHOPHYSIOLOGY The underlying abnormality in all seizures is the hypersynchrony of neuronal discharges Cerebral manifestations include increased blood flow, increased oxygen and glucose consumption, and increased carbon dioxide and lactic acid production If a patient can maintain appropriate oxygenation and ventilation, the increase in cerebral blood flow is usually sufficient to meet the initial increased metabolic requirements of the brain Brief seizures rarely produce any lasting effects Multiple animal studies and a recent study in humans indicate that 30 minutes of generalized convulsive status epilepticus increases the risk of permanent neuronal injury Systemic alterations may occur with seizures and result from a massive sympathetic discharge, leading to tachycardia, hypertension, and initially stress hyperglycemia Failure of adequate ventilation, especially in patients in whom