As a ringside physician, how should I manage a patient who suffered a head injury with loss of consciousness and a seizure lasting under five minutes?

Ringside Management of Post-Knockout Seizure

Activate emergency medical services immediately, place the patient in the recovery position on their side, stay with them continuously, and do not allow them to return to competition—this patient requires urgent hospital evaluation for traumatic brain injury with loss of consciousness and post-traumatic seizure. 1

Immediate Actions at Ringside

Primary Safety Measures

• Help the patient to the ground if still seizing and clear the area around them of any equipment or obstacles that could cause injury 1
• Place the patient on their side in the recovery position to reduce aspiration risk if vomiting occurs during the postictal period 1
• Stay with the patient continuously and monitor their level of consciousness, breathing, and any repeat seizure activity 1

Critical "Do Not" Actions

• Do not restrain the patient during seizure activity 1
• Do not put anything in the patient's mouth including bite blocks, tongue depressors, or any objects 1
• Do not give any food, liquids, or oral medications to the patient who has decreased responsiveness after the seizure 1

Why EMS Activation is Mandatory

This patient meets multiple criteria requiring emergency medical services activation according to the 2024 American Heart Association guidelines 1:

• Seizure with traumatic injury (knockout blow to the head) 1
• Loss of consciousness preceding the seizure 1
• Likely first-time seizure in the context of acute head trauma 1

Even though the seizure lasted under 5 minutes, the combination of head trauma with loss of consciousness followed by seizure represents a medical emergency requiring urgent neuroimaging and neurosurgical evaluation 1.

Post-Seizure Monitoring Until EMS Arrives

Neurological Assessment

• Monitor for return to baseline mental status—if the patient does not return to baseline within 5-10 minutes after seizure cessation, this is an additional indication for urgent transport 1
• Watch for repeat seizure activity—multiple seizures without return to baseline between episodes represents status epilepticus and requires immediate advanced care 1
• Assess for signs of increased intracranial pressure: worsening headache, repeated vomiting, progressive confusion, or deteriorating consciousness 1, 2

Airway and Breathing

• Maintain airway patency in the recovery position 1
• Monitor respiratory effort—difficulty breathing is an additional criterion for urgent EMS activation 1
• If the patient requires airway management, avoid hyperventilation unless there are signs of herniation, as hypocapnia can worsen cerebral ischemia 1, 3

Hospital Management Considerations

Imaging Requirements

• Head CT is mandatory to identify acute intracranial hemorrhage, skull fractures, or mass effect requiring neurosurgical intervention 2, 4
• CT identifies 100% of acutely treatable lesions in post-traumatic seizure patients, with approximately 7% requiring urgent surgical intervention 2, 4

Seizure Prophylaxis Decision

• Antiepileptic prophylaxis is not routinely recommended for all traumatic brain injuries 2, 4
• However, if prophylaxis is used in the acute setting (first 7 days), levetiracetam is strongly preferred over phenytoin due to better tolerability and fewer drug interactions 2, 4, 5
• Phenytoin should be specifically avoided as it is associated with excess morbidity and mortality in subdural hematoma patients 4

Critical Pitfalls to Avoid

Common Errors

• Never allow the patient to "shake it off" and continue fighting—loss of consciousness with subsequent seizure mandates immediate removal from competition and hospital evaluation 1
• Do not assume a brief seizure is benign—early post-traumatic seizures occur in only 2.2% of all TBI cases but indicate significant brain injury, with risk factors including loss of consciousness and intracranial hemorrhage 2, 4
• Do not delay EMS activation to "see if they improve"—the combination of knockout with seizure requires urgent neuroimaging regardless of subsequent clinical improvement 1, 2

Risk Stratification

This patient has multiple high-risk features for significant intracranial pathology 2, 4:

• Loss of consciousness from direct head trauma
• Post-traumatic seizure
• Mechanism consistent with significant force (knockout blow)

The presence of these factors substantially increases the likelihood of intracranial hemorrhage, skull fracture, or other neurosurgical emergencies requiring immediate intervention 2, 4.