From the Guidelines
For an 8-year-old experiencing a seizure after a fall with head strike, immediate medical attention is essential, and the child should be taken to the emergency department for further evaluation and treatment. While waiting for help, place the child on their side in the recovery position to prevent aspiration, remove any nearby objects that could cause injury, and do not put anything in their mouth. Do not restrain the child during the seizure.
Initial Assessment and Treatment
Medical professionals will likely perform neuroimaging (CT scan or MRI) to rule out intracranial bleeding or other traumatic brain injuries, as recommended by 1. If the seizure is prolonged (lasting more than 5 minutes), emergency personnel may administer benzodiazepines such as midazolam or diazepam. According to 1 and 1, the treatment for convulsive status epilepticus includes administering lorazepam 0.1 mg/kg (maximum 2 mg) i.v., and levetiracetam 40 mg/kg (maximum 2,500 mg) i.v. bolus.
Antiepileptic Medication
The decision to initiate antiepileptic medication should be made on a case-by-case basis, considering the risk of recurrence and the presence of underlying brain disease or injury. As stated in 1, prevention of post-traumatic seizures with antiepileptic drugs cannot be recommended, but it can be considered in case of risk factors. Levetiracetam should be preferred to phenytoin due to a higher degree of tolerance. According to 1, for patients with a first unprovoked seizure, the strategy of waiting until a second seizure before initiating antiepileptic medication is considered appropriate.
Follow-up and Observation
After stabilization, the child may require observation for 24-48 hours and follow-up with a pediatric neurologist to determine the cause and risk of recurrence. Post-traumatic seizures can occur due to direct brain injury, cerebral edema, or intracranial hemorrhage, making prompt evaluation crucial to identify and treat the underlying cause. Maintenance antiepileptic medication like levetiracetam might be prescribed, depending on the cause and risk of recurrence.
From the FDA Drug Label
Valproic acid is indicated as monotherapy and adjunctive therapy in complex partial seizures in adults and pediatric patients down to the age of 10 years, and in simple and complex absence seizures. For adults and children 10 years of age or older. The dosage should be increased by 5 to 10 mg/kg/week to achieve optimal clinical response Ordinarily, optimal clinical response is achieved at daily doses below 60 mg/kg/day.
The patient is 8 years old, and the valproate label only provides information for patients 10 years of age or older. No treatment recommendation can be made based on the provided drug label for an 8-year-old patient 2.
From the Research
Treatment Recommendations for 8-Year-Old with Seizure after Fall and Head Strike
- The treatment for an 8-year-old who experienced a seizure after a fall and head strike depends on various factors, including the severity of the injury and the presence of other trauma [ 3 ].
- Studies have compared the effectiveness of levetiracetam and phenytoin in preventing post-traumatic seizures in patients with traumatic brain injury [ 3 ].
- Levetiracetam has been shown to have a better side effect profile compared to phenytoin, but its ability to reach therapeutic levels in the cerebrospinal fluid (CSF) quickly is still unclear [ 3 ].
- A study published in 2011 found that levetiracetam is associated with improved cognitive outcome for patients with intracranial hemorrhage compared to phenytoin [ 4 ].
- Another study published in 2022 found that levetiracetam may be preferred for seizure prophylaxis after supratentorial neurosurgery, but its effectiveness in preventing seizures in patients with traumatic brain injury, subarachnoid hemorrhage, or intracerebral hemorrhage is still unclear [ 5 ].
- A 2023 study evaluated different dosing strategies of levetiracetam for seizure prophylaxis following traumatic brain injury and found no statistically significant difference in the cumulative incidence of early posttraumatic seizures between three different levetiracetam dosing strategies [ 6 ].
- The American Academy of Neurology recommends the use of levetiracetam or phenytoin for seizure prophylaxis in patients with traumatic brain injury, but the optimal dosing strategy is still unclear [ 7 ].
Medication Options
- Levetiracetam: may be preferred for seizure prophylaxis after supratentorial neurosurgery, but its effectiveness in preventing seizures in patients with traumatic brain injury, subarachnoid hemorrhage, or intracerebral hemorrhage is still unclear [ 5 ].
- Phenytoin: has been shown to reach therapeutic levels in the CSF quickly, but has a larger side effect profile compared to levetiracetam [ 3 ].
Dosing Strategies
- Levetiracetam: different dosing strategies (≤ 1000 mg/day, 1500 mg/day, and ≥ 2000 mg/day) have been evaluated, but no statistically significant difference in the cumulative incidence of early posttraumatic seizures was found [ 6 ].