Immediate Management of Pediatric Traumatic Brain Injury with Post-Traumatic Seizure
Activate emergency medical services immediately and do not allow the child to move—this child has a high-risk traumatic brain injury requiring urgent neurosurgical evaluation and CT imaging. 1, 2
Why This is a Neurosurgical Emergency
This child meets multiple high-risk criteria that mandate immediate EMS activation and hospital transport:
- Post-traumatic seizure with traumatic injury requires EMS activation per American Heart Association guidelines 1
- Altered mental status (sleepiness/somnolence) automatically classifies this as high-risk severe head trauma 1, 2
- Vomiting after head trauma is a high-risk feature for clinically important brain injury 1
- Visible head swelling suggests significant impact force and possible skull fracture 1
The combination of seizure, vomiting, altered mental status, and visible swelling indicates this child likely has intracranial hemorrhage (epidural or subdural hematoma) or significant brain injury requiring immediate intervention. 2, 3
Critical First Aid Actions Before EMS Arrives
Seizure management (if still seizing or recurs): 1
- Help the child to the ground if not already down
- Place in recovery position (on side) to prevent aspiration if vomiting recurs
- Clear the area of objects that could cause injury
- Do NOT restrain the child or put anything in the mouth 1
- Stay with the child continuously 1
Spinal precautions: 1
- Keep the child still and discourage movement
- The mechanism (fall from height) combined with altered mental status raises concern for cervical spine injury 1
Monitor for deterioration: 1, 2
- Worsening sleepiness or inability to wake
- Repeated vomiting
- Seizure recurrence
- Visual changes or pupil abnormalities
Why Observation at Home is Dangerous
Children with post-traumatic seizures have a 16% rate of traumatic brain injury on CT scan requiring hospitalization, and some require emergency craniotomy. 4 This child's additional risk factors (vomiting, altered mental status, visible swelling) place the risk substantially higher—likely in the 23-44% range for intervention-requiring intracranial injury. 1, 5
Secondary brain injury from hypoxemia or hypotension carries a 75% mortality rate in pediatric TBI. 3 The window for optimal surgical intervention can close rapidly—epidural hematomas can expand within minutes to hours, causing herniation and death. 2, 5
What Will Happen at the Hospital
Immediate CT scan of the head without delay is the standard of care for this presentation. 1, 2 The American College of Radiology designates urgent non-contrast head CT as "usually appropriate" (rating 9/9) for children with this risk profile. 1
Neurosurgical consultation will be obtained emergently if CT shows: 2, 3
- Epidural or subdural hematoma with mass effect
- Depressed or open skull fracture
- Brain swelling or midline shift
- Any expanding intracranial lesion
Intracranial pressure monitoring may be required if the child has severe TBI (Glasgow Coma Scale ≤8) with abnormal CT findings, targeting ICP <20 mmHg. 2, 3
Common Pitfall to Avoid
Do not assume this is "just a concussion" because the child is awake and talking. The combination of post-traumatic seizure, vomiting, and altered mental status represents a neurosurgical emergency until proven otherwise by CT imaging and neurosurgical evaluation. 2, 5 Delayed recognition of expanding intracranial hematomas is a preventable cause of death in pediatric head trauma. 3, 6
Prognosis Context
Even with optimal management, children with moderate-to-severe TBI have only approximately 51% chance of good recovery, with 48% experiencing moderate disability and significant risk of long-term cognitive impairment. 3 However, immediate recognition, EMS activation, and prevention of secondary brain injury through rapid hospital transport dramatically improves outcomes. 2, 3, 6