What is the management for a 2-year-old who has had two seizures, each lasting less than one minute, following a traumatic injury, with the seizures occurring 13 days apart?

Management of Post-Traumatic Seizures in a 2-Year-Old Child

A 2-year-old child with two brief post-traumatic seizures occurring 13 days apart requires immediate medical evaluation, including emergency medical services (EMS) activation, and likely warrants long-term antiseizure medication due to the high risk of recurrence.

Initial Management

Emergency Medical Services Activation

• EMS should be activated for this child based on multiple high-risk factors 1:
  • First-time seizure (the initial post-traumatic seizure)
  • Multiple seizures (two episodes)
  • Traumatic injury as the precipitating factor
  • Young age (2 years old)

Immediate Care During a Seizure

• Place the child on their side in the recovery position
• Clear the area around the child to prevent injury
• Do not restrain the child during seizures
• Do not put anything in the child's mouth
• Stay with the child until full recovery 1

Medical Evaluation

Neurological Assessment

• Assess for return to baseline mental status after seizures
• Document seizure characteristics (duration, focal vs. generalized features)
• Evaluate for any post-ictal deficits or focal neurological signs

Diagnostic Workup

• Neuroimaging may be indicated given the traumatic etiology:
  • MRI is preferred over CT for better visualization of parenchymal injury, though CT may be used in acute settings 1
  • Imaging helps identify treatable pathology and children at greater risk for seizure recurrence 1

Treatment Approach

Antiseizure Medication Initiation

• The occurrence of two seizures following traumatic brain injury indicates a high risk for developing post-traumatic epilepsy
• Research shows that children with severe TBI have a 25.2% rate of post-traumatic seizures, with younger age being a significant risk factor 2
• Long-term studies indicate that patients with a single late post-traumatic seizure (>7 days post-trauma) have an 82% risk of seizure recurrence at 10 years 3

Medication Selection

• For a 2-year-old child, medication options include:

  1. First-line options:

     • Levetiracetam: Generally well-tolerated with fewer cognitive side effects
     • Oxcarbazepine: Good efficacy for focal seizures with favorable side effect profile

  2. Alternative options (with caution):

     • Valproate: Effective but carries a BOXED WARNING for hepatotoxicity, especially in children under 2 years of age 4
     • Diazepam: For acute seizure management only, not for long-term therapy due to risk of dependence 5

Important Medication Considerations

• Valproate requires extreme caution in this age group:
  • Children under 2 years have considerably increased risk of fatal hepatotoxicity
  • Should only be used as a sole agent if prescribed
  • Regular liver function monitoring required, especially in first 6 months 4
  • Benefits must clearly outweigh risks

Follow-up and Monitoring

Seizure Monitoring

• Keep a detailed seizure diary (frequency, duration, characteristics)
• Follow up with a pediatric neurologist within 1-2 weeks
• Monitor for medication side effects

Duration of Treatment

• Long-term treatment is likely warranted given:
  • Multiple seizures have already occurred
  • Young age is a risk factor for recurrence
  • Studies show high recurrence rates (up to 82%) after a single late post-traumatic seizure 3
  • The cumulative incidence of post-traumatic epilepsy is 25% at 5 years 3

Discontinuation Considerations

• Typically, seizure-free period of at least 2 years before considering medication withdrawal
• Decision should be made by a pediatric neurologist based on:
  • EEG findings
  • Neuroimaging results
  • Seizure-free duration
  • Type and severity of the initial trauma

Prognosis and Risk Factors

• Young age, traumatic brain injury, and multiple seizures are all significant risk factors for developing epilepsy
• The triad of young age, traumatic injury, and intracranial hemorrhage (if present) confers the greatest risk for post-traumatic seizures 2
• The cumulative incidence of post-traumatic epilepsy increases over time, reaching 32% at 15 years 3

Family Education

• Educate caregivers on seizure first aid
• Explain the importance of medication adherence
• Teach recognition of seizure activity and when to seek emergency care
• Discuss potential medication side effects to monitor