This is the second in our series of talks recorded live in June 2023 at the PREMIER conference.

Looking after patients with non-epileptiform seizures are a challenging, and common, event in the Emergency Department. 10% of attendances at paediatric neurology clinics are thought to be 'functional' and a lot of these will also present to the ED. These problems can involve a wide range of physical or sensory manifestations, almost all of wide have significant differentials which we cannot miss.

A large number of these patients can end up with an incorrect diagnosis, some of this due to confirmation bias by clinicians, but also some with psychogenic non-epileptiform seizures may coexist with organic problems.

The history is key and can be helped significantly by watching videos of events. There may be other factors giving a clue to a non-epileptic cause. Sometimes this will only happen in one place, like school, and the history may be inconsistent. Awareness and generalised bilateral movements, with episodes that are different each time all point to a non epileptiform origin. And then there are symptoms just 'not fitting' with our knowledge of dermatomal distribution.

There are Red Flags - Events happening during exercise, neurological signs, unpredictability and patterns to the events all point to a more sinister diagnosis

Management is incredibly difficult, particularly in trhe ED. Don't suggest an organic diagnosis and leave some ambiguity. There is time to get more information and there are few definitive diagnostic tests. EEGs are notoriously unreliable. Self help groups can help.

Steve Warriner has worked as a paediatrician at the QA in Portsmouth for the last 16 years. He trained in various regions in the UK including the Midlands, Yorkshire and the North East of England before working in Somerset for a brief period. He has a particular interest in epilepsy and neurological conditions in children and lead the district epilepsy service in Portsmouth. He teaches on the British Paediatric Neurology Association epilepsy training courses both in the UK and across the world. He was part of the team who designed and implemented the training course (initially in Myanmar) and the method of cascade training has recently been recognised by the World Health Organisation and the course now runs in nearly 30 counties in 3 languages. Steve recently chaired a multidisciplinary working group to update the Advanced Life Support Group guideline for management of prolonged seizures. In his spare time, Steve is a triathlete who qualified for and competed in the World Ironman Championship race in Hawaii in 2022.