What is the emergency management of a seizure in a patient following a road traffic accident?

Emergency Management of Post-Traumatic Seizure Following Road Traffic Accident

Activate emergency medical services immediately and protect the patient from injury during the seizure—this is a neurosurgical emergency requiring urgent CT imaging and hospital evaluation, not a condition for home observation. 1

Immediate First Aid Actions (Before EMS Arrives)

During the active seizure:

• Help the patient to the ground if not already down 1
• Place the patient on their side in the recovery position to reduce aspiration risk 1
• Clear the area around them of objects that could cause injury 1
• Stay with the patient throughout the seizure 1
• Never restrain the patient or put anything in their mouth 1
• Maintain spinal precautions given the trauma mechanism—minimize movement of the head and neck 2

After the seizure stops:

• Do not give anything by mouth (no food, liquids, or oral medications) if the patient has decreased responsiveness 1
• Monitor for respiratory distress 1
• Note the time the seizure started and stopped 1

Why EMS Activation is Mandatory

This presentation meets multiple criteria requiring emergency medical services: 1

• Seizure with traumatic injury (the road traffic accident) 1
• First-time seizure in the context of trauma 1
• If seizure lasts >5 minutes, this represents status epilepticus requiring immediate anticonvulsant medications 1
• If multiple seizures occur without return to baseline between episodes 1

Hospital Emergency Management

Immediate Resuscitation Priorities

Airway and breathing management:

• Intubate immediately if Glasgow Coma Scale ≤8, deteriorating consciousness, loss of protective airway reflexes, or inability to maintain adequate oxygenation 3
• Maintain normocapnia with PaCO₂ between 35-40 mmHg (4.5-5.0 kPa) to prevent secondary brain injury 1, 3
• Target PaO₂ ≥13 kPa or oxygen saturation ≥95% 3
• Monitor end-tidal CO₂ continuously in intubated patients 3

Hemodynamic stabilization:

• Maintain systolic blood pressure >110 mmHg—even a single episode of hypotension dramatically worsens neurological outcomes 3
• Stabilize hemorrhage and hemodynamics before proceeding to CT imaging if the patient is hemodynamically unstable 1

Active Seizure Management in the Emergency Department

For ongoing seizures or status epilepticus:

• Administer intravenous benzodiazepine first-line (diazepam or lorazepam) for rapid seizure control 1, 4, 5
• Lorazepam 2 mg IV (with additional 2 mg IV if needed) or diazepam 5 mg IV (with additional 5 mg IV if needed) 5
• Inject slowly—at least one minute for each 5 mg of diazepam 4
• If seizures do not terminate after benzodiazepines, administer phenytoin 15-20 mg/kg IV at a rate not exceeding 50 mg per minute in adults (or 1-3 mg/kg/min in pediatrics, whichever is slower) 6
• Continuous monitoring of electrocardiogram, blood pressure, and respiratory function is essential during phenytoin administration 6
• If seizures persist despite these measures, consider intravenous barbiturates, general anesthesia, and other anticonvulsants 6

Urgent Neuroimaging

Obtain urgent non-contrast head CT immediately once hemodynamics and respiratory function are stabilized: 1, 3

• Whole-body CT scan is more effective than segmental CT in reducing mortality in severe trauma patients 1
• Include cervical spine CT in all severe head trauma patients 1, 3
• Do not delay imaging in patients with any history of lucid interval, even if currently appearing stable—deterioration can be sudden and catastrophic 3

Seizure Prophylaxis Decision

Antiepileptic drugs for primary prevention are NOT routinely recommended: 1

• Multiple studies show no significant effect of antiepileptic drugs in preventing early or delayed post-traumatic seizures 1
• Phenytoin and valproate show increased side effects and may worsen neurological outcomes 1
• The incidence of early clinical seizures (within 7 days) after traumatic brain injury is only 2.2% overall, though 11.9% in severe TBI 1

Consider prophylaxis only in specific high-risk situations: 1

• Brain contusion, acute subdural hematoma, skull fracture, loss of consciousness >24 hours, age >65 years, or craniectomy 1
• If prophylaxis is used, levetiracetam should be preferred over phenytoin due to better tolerance 1
• However, levetiracetam does not reach therapeutic CSF levels when loaded at standard dosing in the acute setting 7
• Phenytoin reaches therapeutic CSF levels when dosages approximate weight-based dosing 7

Critical Pitfalls to Avoid

• Never delay neuroimaging in post-traumatic seizure patients, even if they appear stable after the seizure 3
• Never use hypotonic fluids—use 0.9% saline to avoid worsening cerebral edema 3
• Never employ prolonged hyperventilation—this causes cerebral ischemia 3
• Never allow hypotension in traumatic brain injury patients, even when hemorrhagic shock is present elsewhere 1, 3
• Never assume the patient can be safely observed at home—post-traumatic seizures indicate significant brain injury requiring hospital evaluation 2

Disposition

Admission is required for: 1

• All patients with post-traumatic seizures given the provoked nature and high risk of intracranial pathology 1
• Patients with abnormal CT findings requiring neurosurgical consultation 3
• Patients who do not return to clinical baseline within 5-10 minutes after seizure activity stops 1