What is the next best step for a patient who fell from a tree, hit their head, had a brief loss of consciousness followed by a seizure, and is now in a post-ictal state but arousable with equal and reactive pupils and no focal neurological deficits?

Urgent Non-Contrast CT is the Next Best Step

For a pediatric patient who fell from a tree, sustained head trauma with brief loss of consciousness followed by a post-traumatic seizure, urgent non-contrast CT head imaging is indicated and should be performed immediately, even though the patient is now arousable with normal pupils and no focal deficits. 1

Rationale for Immediate CT Imaging

Post-Traumatic Seizure as High-Risk Feature

• Post-traumatic seizures are an independent indication for urgent neuroimaging in head trauma patients, regardless of current neurological status 1
• The ACR Appropriateness Criteria specifically identifies post-traumatic seizures as requiring CT imaging in the acute setting, with CT being the preferred initial modality to identify acute intracranial hemorrhage or mass effect 1
• Post-traumatic seizures occur in 2.4% of mild traumatic brain injuries but up to 28-83% in severe cases, and their presence indicates higher risk for intracranial pathology requiring intervention 1

Additional High-Risk Features Present

• Dangerous mechanism of injury (fall from height >3 feet/5 stairs) is explicitly listed as a high-risk criterion requiring CT imaging 1, 2, 3
• Loss of consciousness, even if brief, combined with post-traumatic seizure creates a Level A recommendation for non-contrast head CT 1
• The post-ictal state does not exclude serious intracranial injury; patients with seizures due to head trauma have a 90.9% incidence of intracranial hematomas, with 81.8% requiring surgical evacuation 4

Why Observation Alone is Inadequate

• Patients with head injuries from falls caused by seizures have significantly higher rates of mass lesions (90.9% vs 39.8%) and need for surgical evacuation (81.8% vs 32.3%) compared to other fall mechanisms 4
• The post-ictal state can mask evolving neurological deterioration from expanding hematomas, making clinical observation unreliable without baseline imaging 1, 4
• CT identified 100% of acutely treatable lesions in mild trauma patients, and 7% of patients with initially negative clinical presentations required urgent surgical intervention 1

Critical Timing Considerations

• CT imaging should not be delayed for observation in patients meeting high-risk criteria, as early identification of surgical lesions is time-critical 1
• The combination of post-traumatic seizure, loss of consciousness, and dangerous mechanism creates multiple overlapping Level A indications for immediate imaging 1
• While the patient appears stable now, deterioration can occur rapidly, and baseline imaging is essential before any observation period 1, 2

Pediatric-Specific Considerations

• Although the adult guidelines (age ≥16 years) don't directly apply 1, the ACR pediatric seizure guidelines explicitly recommend CT for post-traumatic seizures to detect treatable pathology 1
• Young age combined with subdural hematoma are independent predictors for post-traumatic seizures, suggesting bidirectional risk 1
• MRI is more sensitive than CT for parenchymal injury but is not practical in the acute trauma setting due to longer scan times and monitoring constraints 1, 5

Common Pitfalls to Avoid

• Do not attribute the current post-ictal state as the sole explanation for any subtle neurological findings without excluding mass lesion first 4
• Do not delay CT imaging to complete a prolonged observation period when clear high-risk features are present 1
• Do not assume that normal pupils and lack of focal deficits exclude significant intracranial injury in the setting of post-traumatic seizure 1, 4

Disposition After CT Results

• If CT is negative, the patient may then be admitted for 24-hour neurological observation with serial examinations every 2-4 hours 2, 3
• If CT shows intracranial pathology, neurosurgical consultation and ICU-level monitoring are indicated 1
• Repeat CT should be obtained if any neurological deterioration occurs during observation 2, 3