What is the appropriate immediate action for a 2-year-old boy who fell downstairs, had brief jerky movements, and is now drowsy and lethargic?

Immediate CT Brain Imaging is Required

This 2-year-old with a fall down stairs, brief jerky movements (likely post-traumatic seizure), and altered mental status (drowsy and lethargic) requires immediate CT brain imaging to rule out intracranial injury before any period of observation. 1

Clinical Reasoning

Why CT Brain is the Correct Answer

• Post-traumatic seizure activity (the "brief jerky movements") in a young child following head trauma is a red flag that mandates neuroimaging, as it suggests significant brain injury or increased intracranial pressure 1

• Altered mental status (drowsy and lethargic) represents a critical finding that cannot be attributed to normal post-ictal state alone without first excluding life-threatening intracranial pathology such as epidural hematoma, subdural hematoma, or cerebral contusion 1

• The combination of mechanism (fall down stairs), seizure activity, and altered consciousness creates a high-risk clinical picture where delayed diagnosis could result in herniation and death 1

Why Other Options are Inappropriate

Observation alone (Option B) is dangerous because:

• You cannot safely observe a child with altered mental status and post-traumatic seizure without first ruling out surgical lesions 1
• Epidural hematomas can evolve rapidly in young children, and the "lucid interval" may be brief or absent 2
• Waiting to see if symptoms improve wastes critical time when neurosurgical intervention may be needed 1

Blood electrolytes (Option C) are not the priority because:

• While electrolyte abnormalities can cause seizures, the temporal relationship to trauma makes this a traumatic brain injury until proven otherwise 1
• Electrolyte testing does not address the immediate life-threatening concern of intracranial hemorrhage 1
• This would only delay definitive diagnosis 1

Direct neurosurgery referral (Option D) is premature because:

• You need imaging first to determine if neurosurgical intervention is actually required 1
• Not all head injuries require surgery, but you cannot make this determination clinically 1
• The neurosurgeon will demand imaging before accepting the patient 1

Critical Clinical Pearls

High-Risk Features Present in This Case

• Age under 2 years: Young children have thinner skulls and are at higher risk for intracranial injury from falls 3, 4

• Seizure activity: Post-traumatic seizures indicate significant brain injury and correlate with worse outcomes 1, 5

• Altered consciousness: Drowsiness and lethargy after head trauma suggest either increased intracranial pressure or diffuse brain injury 1

Common Pitfalls to Avoid

• Do not assume the seizure was "just" a brief post-traumatic event without imaging—this assumption can be fatal if an expanding hematoma is present 1

• Do not be falsely reassured by a "minor" mechanism (fall down stairs)—skull fractures and intracranial injuries occur in children who fall from heights as low as 80-90 cm, especially onto hard surfaces 4

• Do not delay imaging to obtain laboratory studies unless the child is hemodynamically unstable and requires immediate resuscitation 1

• Do not wait for the child to "wake up" before imaging—progressive lethargy may indicate evolving herniation 1

Immediate Management Algorithm

1. Stabilize airway, breathing, circulation while preparing for CT 1

2. Obtain non-contrast CT brain immediately to identify surgical lesions 1

3. Based on CT results:

   • If surgical lesion present → immediate neurosurgery consultation 1
   • If significant injury but no surgical lesion → ICU admission for monitoring 1
   • If normal CT but persistent altered mental status → consider MRI and continued observation 1

4. Do not discharge a child with altered mental status even if CT is normal—admission for neurological monitoring is required 1