Emergency Management of Post-Traumatic Seizure in a Child
Perform an emergent non-contrast brain CT scan immediately – this is the definitive first step for a child who fell from a tree and had a seizure, as post-traumatic seizures require urgent imaging to identify life-threatening intracranial pathology such as hemorrhage, mass effect, or skull fractures that may require immediate intervention 1, 2.
Immediate Imaging Priority
Brain CT without contrast is the imaging modality of choice in this acute setting because:
- It rapidly identifies acute intracranial hemorrhages, cerebral edema, vascular malformations, hydrocephalus, skull fractures, and mass effect requiring urgent intervention 1
- It can quickly detect tonsillar herniation or midline shift necessitating emergent neurosurgical management 1
- The combination of recent head trauma and seizure creates high priority for obtaining imaging, as this identifies structural abnormalities with high probability 1
- CT is performed quickly without need for ferromagnetic screening, making it superior to MRI in the acute traumatic setting 1
Neurological Examination
A thorough neurological examination must be performed concurrently with imaging preparation to assess for:
- Focal neurological deficits (particularly persistent Todd's paresis) 3, 4, 5
- Return to baseline mental status 2, 6, 3
- Glasgow Coma Score 7
- Signs of increased intracranial pressure 6
The neurological examination helps risk-stratify but does not replace the need for emergent CT – even children with normal neurological examinations can have clinically significant intracranial lesions after post-traumatic seizures 1.
24-Hour Monitoring Considerations
Hospital admission for neurological monitoring is indicated in this scenario because:
- Post-traumatic seizures warrant brief observation even when CT is normal, as complications may develop 7
- Children with immediate post-traumatic seizures (within 24 hours of injury) require monitoring for recurrent seizures and neurological deterioration 7
- However, the CT scan must be performed first – monitoring alone without imaging is inadequate for a child with post-traumatic seizure 1, 2
Critical Pitfalls to Avoid
Do not defer imaging for outpatient follow-up in post-traumatic seizures – the combination of head trauma and seizure mandates emergent evaluation regardless of return to baseline 1, 2.
Do not rely solely on clinical examination – studies show that 6-7% of patients with post-traumatic seizures and normal neurological examinations have acute lesions on CT 1.
Do not order MRI as the initial study – while MRI is more sensitive for subtle injuries, CT's speed and ability to identify acute hemorrhage and mass effect make it the appropriate first-line modality in trauma 1.
Answer to Multiple Choice Question
The correct answer is C (brain CT) as the immediate priority, though A (neurological examination) should be performed concurrently, and B (24-hour monitoring) follows after imaging 1, 2.
The neurological examination and monitoring are important components of management, but emergent CT is the critical first step that cannot be deferred in a child with post-traumatic seizure 1, 2.