A 2‑year‑old boy fell down stairs, had a brief seizure and remains 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, post-traumatic seizure, and persistent drowsiness/lethargy, obtain an urgent non-contrast CT brain immediately—this combination mandates emergent neuroimaging before any other intervention. 1, 2

Why This is a Neurosurgical Emergency

The clinical presentation places this child in the highest-risk category for clinically important traumatic brain injury:

• Post-traumatic seizure with traumatic injury requires EMS activation and hospital evaluation per American Heart Association guidelines 3
• Persistent altered mental status (drowsiness/lethargy beyond 5-10 minutes post-seizure) indicates either prolonged seizure activity or underlying structural brain injury, not simple post-ictal confusion 2
• Children with post-traumatic seizures have a 16% rate of traumatic brain injury on CT requiring hospitalization, with some requiring emergency craniotomy 1
• When additional risk factors are present (altered mental status persisting beyond the expected post-ictal period), the risk of intervention-requiring intracranial injury rises to 23-44% 1

Why Observation is Dangerous

• Post-ictal confusion normally resolves within 5-10 minutes after a brief seizure 3, 2
• Lingering drowsiness or lethargy beyond this window suggests structural brain injury, not metabolic causes 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
• Observation alone is unsafe when altered consciousness persists after a seizure—definitive imaging must precede watchful waiting 2

Why Not Blood Electrolytes First

• Laboratory investigations should never postpone the CT scan in a child with head trauma and ongoing altered mental status 2
• Metabolic causes of seizures can be predicted from history and physical examination in >95% of cases; in the setting of trauma with altered consciousness, structural injury must be the primary focus 2
• Bedside glucose can be checked concurrently with CT preparation, but must not delay imaging 2
• Hypoglycemia would not explain the mechanism of injury (fall down stairs) or the persistent altered mental status in this context 4

Why Not Neurosurgery Referral First

• Neurosurgical consultation is appropriate after the CT scan, once the presence and nature of any intracranial lesion are known 2
• Calling neurosurgery without imaging data provides no actionable information and delays definitive diagnosis 1
• The neurosurgeon will immediately ask "What does the CT show?" before making management recommendations 1

Critical Management Algorithm

Before CT:

• Stabilize airway and circulation, maintaining systolic blood pressure >110 mmHg—even single episodes of hypotension markedly increase mortality in pediatric head trauma 1, 2
• Check bedside glucose simultaneously with CT preparation (but do not delay imaging) 2

CT Protocol:

• Non-contrast CT head using pediatric protocols with bone-window reconstructions 2
• Multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages 2

After CT:

• Request neurosurgical consultation if CT shows intracranial hemorrhage, significant fractures, or mass effect 2
• Consider CT angiography if basilar skull fracture is identified (high risk for arterial dissection) 2

Common Pitfalls to Avoid

• Do not assume a brief seizure explains persistent drowsiness—this child should have returned to baseline within 5-10 minutes 3, 2
• Do not delay imaging for laboratory studies in traumatic brain injury with altered mental status 2
• Do not give anything by mouth to a child with decreased responsiveness after seizure due to aspiration risk 3, 1