Management of a Child with Post-Traumatic Seizure
For a child who presents to the ER with a seizure following head trauma and is now vitally stable, perform a CT head without contrast emergently to rule out intracranial injury requiring neurosurgical intervention. 1, 2, 3
Rationale for Emergent Neuroimaging
The combination of head trauma and seizure places this child at significantly elevated risk for traumatic intracranial hematoma and requires immediate CT evaluation. 4
Patients with head injuries due to falls caused by seizures have a 90.9% incidence of intracranial hematomas, with 81.8% requiring surgical evacuation—significantly higher than falls from other causes (39.8% and 32.3% respectively). 4
In pediatric head trauma, 35% of severely head-injured children experience posttraumatic seizures, and 94.5% of these occur within the first 24 hours. 5
The CDC guideline on pediatric mild traumatic brain injury defines this population as requiring evaluation for potential intracranial injury, particularly when seizures occur as a transient neurological abnormality following trauma. 1
Specific Imaging Approach
CT head without contrast is the appropriate emergent imaging modality in this scenario. 2, 3
The American College of Emergency Physicians recommends emergent CT when there is recent head trauma with new neurological symptoms (seizure qualifies). 2
While MRI is preferred for non-emergent seizure evaluation, CT is acceptable and appropriate when rapid identification of structural pathology such as intracranial hemorrhage is needed. 1, 2
The American Academy of Pediatrics recommends emergent neuroimaging if the patient has not returned to baseline within several hours after the seizure or exhibits a postictal focal deficit that does not quickly resolve. 2, 3
Critical Assessment Points
Before deciding on disposition, confirm the child has returned to neurological baseline. 2, 3
If the child has not returned to baseline within 5-10 minutes after seizure cessation, this warrants emergency medical intervention and emergent neuroimaging. 1, 3
The mean time to first seizure recurrence is 121 minutes (median 90 minutes), with more than 85% of early seizures recurring within 360 minutes (6 hours). 2, 3
Why Other Options Are Incorrect
Admission for observation alone (Option B) is inadequate without first obtaining neuroimaging. 4
Any decrease in level of consciousness or focal neurological deficit should not be attributed to the seizure itself until a mass lesion has been excluded by CT. 4
The high incidence of surgically significant hematomas (81.8%) in seizure-related head injuries makes imaging mandatory before determining disposition. 4
Discharge with instructions (Option C) is inappropriate and potentially dangerous. 2, 4
While discharge may be appropriate for uncomplicated first-time seizures without trauma, the combination of head injury and seizure requires imaging to exclude intracranial pathology. 2
The American College of Emergency Physicians recommends that patients with first unprovoked seizures who have returned to baseline need not be admitted, but this applies to non-traumatic seizures only. 2
Urgent craniotomy (Option D) is premature without diagnostic imaging. 4
- Surgical intervention should be based on CT findings demonstrating a surgically significant lesion, not performed empirically. 4
Common Pitfalls to Avoid
Do not attribute altered mental status solely to postictal state in the setting of head trauma—always exclude structural injury first. 4
Do not delay CT imaging in children with post-traumatic seizures, even if they appear to have returned to baseline, as mass lesions may be present without obvious clinical signs. 4
Do not assume a brief seizure following head trauma is benign—the seizure itself may indicate underlying intracranial injury requiring intervention. 5