A 2‑year‑old boy who fell down stairs, had a brief seizure, and is now drowsy and lethargic—what is the most appropriate next step in management?

CT Brain is the Most Appropriate Next Step

In a 2-year-old with head trauma, brief seizure, and persistent altered mental status (drowsy and lethargic), immediate non-contrast CT brain is mandatory before any other intervention. 1, 2

Why This Child is High-Risk and Requires Immediate CT

This presentation places the child in the highest risk category for traumatic brain injury requiring urgent imaging:

• Post-traumatic seizure combined with persistent altered consciousness (drowsy/lethargic) indicates potential intracranial pathology that must be ruled out immediately 1, 2
• Failure to return to neurological baseline after the seizure is the single most important predictor of clinically significant intracranial abnormality on CT 3
• The American College of Radiology states that CT head without contrast must be performed without delay in severe traumatic brain injury patients with coma or abnormal neurological examination 1

Why Other Options Are Incorrect

Observation alone is dangerous in this scenario. While children with simple post-traumatic seizures who recover fully in the emergency room and have normal mental status can potentially be observed 4, this child has persistent altered consciousness, which mandates imaging first 1, 3

Blood glucose/electrolytes should not delay CT. Guidelines recommend checking blood glucose only in children who are still convulsing or unrousable 1. While you can obtain a bedside glucose simultaneously, laboratory studies should never delay definitive imaging in a child with head trauma and altered mental status 1, 2

Neurosurgery referral comes after CT, not before. You cannot make an appropriate neurosurgical referral without knowing what intracranial pathology exists 1

Critical Clinical Algorithm

1. Stabilize airway and circulation first - maintain systolic BP >110 mmHg, as even single episodes of hypotension markedly increase mortality in head trauma 1

2. Obtain immediate non-contrast CT head using pediatric protocols with bone windows 1, 2

3. Check bedside glucose while preparing for CT (takes 30 seconds), but do not delay imaging 1

4. Request neurosurgical consultation if CT shows intracranial hemorrhage, significant fractures, or mass effect 2

Key Risk Factors Present in This Case

• Age under 2 years - significantly associated with abnormal neuroimaging in first seizures 5
• Post-traumatic seizure - 28.4% of children with first seizure after trauma have clinically significant CT abnormalities 3
• Persistent altered mental status - the strongest predictor of intracranial pathology, with 98% sensitivity when absent 3

Common Pitfalls to Avoid

Do not assume the seizure explains the altered consciousness. Post-ictal confusion typically resolves within 5-10 minutes for brief seizures 1. Persistent drowsiness/lethargy after a brief seizure suggests either prolonged seizure activity or underlying structural brain injury 1

Do not wait for laboratory results. Metabolic abnormalities causing seizures can be predicted by history and physical examination in >95% of cases 1. In trauma with altered consciousness, structural injury is the primary concern 1, 2

Do not miss basilar skull fracture. Falls down stairs can cause basilar skull fractures even without external wounds, and these carry high risk for arterial dissection requiring CT angiography 1, 2