What is the initial treatment for a patient with a history of seizures following a traumatic fall?

Initial Treatment for Seizures Following Traumatic Fall

For a patient with seizures following a traumatic fall, immediately activate emergency medical services, place the patient in the recovery position to prevent aspiration, protect them from injury, and perform urgent head CT imaging to identify intracranial hemorrhage requiring surgical intervention. 1, 2

Immediate First Aid Management

The 2024 American Heart Association guidelines provide clear Class I recommendations for seizure management following trauma 1:

• Help the person safely to the ground and place them on their side in the recovery position to reduce aspiration risk if vomiting occurs 1
• Clear the area around them to prevent injury from seizure movements, which commonly cause head, body, and extremity trauma 1
• Stay with the person throughout the seizure and postictal period 1
• Do NOT restrain the person, place anything in their mouth, or give oral medications/food/liquids during the seizure or decreased responsiveness 1

When to Activate Emergency Medical Services

EMS must be activated immediately for seizures following traumatic falls because this represents a high-risk scenario 1, 2:

• Seizures with traumatic injuries are an explicit indication for emergency activation 1
• First-time seizures require emergency evaluation 1
• Seizures lasting >5 minutes represent status epilepticus and require emergency anticonvulsant medications 1
• Failure to return to baseline within 5-10 minutes after seizure cessation warrants emergency care 1

Critical Diagnostic Priority: Head CT Imaging

Head CT is the preferred initial imaging modality and should be performed urgently in patients with post-traumatic seizures 2, 3:

• CT identifies 100% of acutely treatable lesions, with approximately 7% requiring urgent surgical intervention 3
• Patients with seizure-related falls have a 90.9% incidence of intracranial hematomas compared to 39.8% in falls from other causes (p<0.001) 4
• 85% of hematomas in seizure-related falls are extraaxial (epidural or acute subdural), which are surgically treatable 4
• 81.8% of patients with seizure-related falls require hematoma evacuation versus 32.3% in other fall mechanisms (p<0.001) 4

Critical pitfall: Do not attribute decreased consciousness or focal neurological deficits to the seizure itself until a mass lesion has been excluded by CT imaging 4

Acute Seizure Termination

If the patient is actively seizing, standard antiepileptic medications should be administered 2:

• Benzodiazepines are first-line agents for active seizures 5
• For generalized tonic-clonic seizures: sodium valproate, levetiracetam, phenytoin, benzodiazepines, propofol, or barbiturates 2
• For myoclonic seizures: propofol, clonazepam, sodium valproate, or levetiracetam 2
• Continuous EEG monitoring should be considered in patients with depressed mental status to detect subtle seizure activity 2, 3

Risk Stratification for Post-Traumatic Seizures

Early post-traumatic seizures occur in approximately 2.2% of all TBI cases, but incidence is much higher with specific risk factors 2, 6:

• Age over 65 years increases seizure risk 2, 6
• Loss of consciousness or amnesia >24 hours is a specific risk factor 6
• Intracranial hemorrhage substantially increases risk 2
• Craniectomy is a possible risk factor 6

Prophylactic Antiepileptic Drug Considerations

Antiepileptic prophylaxis is NOT routinely recommended for primary prevention of post-traumatic seizures 6, 3:

• If AED prophylaxis is used, levetiracetam is preferred over phenytoin due to better tolerability and lack of significant drug interactions 3
• Phenytoin should be avoided as it is associated with excess morbidity and mortality in patients with subdural hematoma 3
• Short-term prophylactic AEDs (≤7 days) may be considered in the immediate post-hemorrhagic period to reduce seizure-related complications 3
• High-dose glucocorticoids should NOT be used after severe traumatic brain injury (Grade 1-, Strong Agreement from Brain Trauma Foundation) 2

Decision Algorithm for Antiepileptic Drug Initiation

For patients who have returned to baseline after the seizure 1:

• Provoked seizures (due to acute trauma): Emergency physicians need not initiate antiepileptic medication in the ED; treat the precipitating condition 1
• First unprovoked seizure without brain disease: Emergency physicians need not initiate antiepileptic medication 1
• First unprovoked seizure WITH remote history of brain disease/injury: Emergency physicians may initiate antiepileptic medication or defer in coordination with other providers 1

Important caveat: The seizure in this scenario is provoked by acute trauma, so long-term AED therapy is typically not indicated unless structural brain injury is identified on imaging that creates ongoing seizure risk 1, 2