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Case Reports: Head Injury and Post Impact Seizure

Prepared by: Patricia Sommer, RN

Case: Head Injury and Post Impact Seizure

Pre-Hospital: The patient is a 9 year old male with no pertinent previous medical history who had seizure like episodes after head trauma. The patient was playing in an after school daycare program when he was picked up by another child, flipped over, and dropped on his head. The fall was unwitnessed by any parent or caretaker, so the timing of events after the fall is uncertain. The patient lost consciousness for an unknown amount o f time, and shortly after regaining consciousness had a seizure lasting greater than 5 minutes. Seizure continued until EMS arrived and gave a dose of versed via peripheral IV. Minutes later, the patient had another seizure which was described as full body shaking, and given a second dose of IV versed, which stopped the seizure. The patient was placed in a c - collar and transported to the ED.

ED Course: Prior to the patient arrival in the ED, a Level 1 trauma was initiated and the patient was met by the team in the ambulance bay and brought to trauma room. A brief report was given to the team by EMS. Upon arrival the patient’s GCS was 9 (M4, E3, V2) and improved to 12 after 10 minutes ( M6, E3 , V3) . Primary and secondary surveys were performed with no traumatic findings. Trauma labs, head and c - spine CT were normal. After evaluation by the surgery and neurosurgery teams the patient was admitted to PICU for further monitoring.

PICU: While in the PICU the patient received acetaminophen and toradol aro und the clock for pain control. Video EEG was obtained while the patient was in awake, drowsy and asleep states. Results of the EEG showed generalized intermittent background slowing with no focal slowing, indicating a mild diffuse cerebral dysfunction, li kely from postictal effect. The patient returned to baseline mental status by the morning of day two of hospital course, but continued to have headache. MRI was performed which showed increased T2 signal level of C5 - C6 and C6 - C7 - suggestive of interspinous ligamentous injury. The patient was discharged on day three of hospi talization pain free and at baseline mental status with c - collar. Discharge instructions included plan to follow up with neurology for concussion symptoms and neurosurgery for neck injury.

Post Discharge: After one month the patient presented to the Emergency room with complaints of sudden onset head pain that was initially R parietal and later localized to L anterior parietal. Motrin was given at home with no relief. Mom reported that at the onset of headache, the patient appeared lethargic and confused. In the ED neuro exam was within normal limits, but he endorsed being woken up from sleep by pain and double vision earlier that day. Head CT showed no acute hemorrhage, mass or in farct. During ED stay patient became bradycardic to 40s while awake which rose to 80 when standing. EKG showed sinus bradycardia. The patient was admitted to the floor for further monitoring and MRI/MRA. MRA of the neck and brain were unremarkable. MRI re vealed a punctate area of susceptibility of the left anterior parietal lobe, concerning for possible bleed. The patient and imaging were evaluated by both neurosurgery and neurology, and no intervention was recommended. The patient was discharged with inst ruction to remain in c - collar until 6 week post injury follow up with neurosurgery.

Topic Review: Post impact seizure and concussion protocol

Traumatic brain injury occurs as a result of external or penetrating force applied to the brain. It is the numb er one cause of death and disability in the pediatric population. However, research is limited in pediatric post head injury seizure and concussion syndromes, so recommendations rely heavy on adult literature. The spectrum of traumatic brain injury ranges from mild concussion to severe trauma with destruction of brain tissue, bleeding, and edema.

Outcomes vary greatly depending on the primary injury and the effectiveness of limiting secondary injury. Post impact and early post traumatic seizures are poten tial causes of secondary brain injury. Early posttraumatic seizures occur from immediately post trauma to up to 7 days post impact, and are typically brief and generalized with a nonfocal neuro exam. While they are not felt to be associated with significan t poor outcomes, delayed seizures have been associated with severe injuries such as intracranial hemorrhage. Children are at greater risk than adults for early posttraumatic seizure. Be cause of this early continuous EEG monitoring is recommended for childr en especially two years and younger who require intensive care admission post traumatic head injury. There are currently no treatment standards for management of pediatric post impact seizures as there is limited research on the subject.

Post discharge c are of patients with mild traumatic brain injury relies heavily on recommendations for concussion symptoms. Research estimates that between 1.1 and 3.8 million concussions occur annually in children in the united states. They may be accompanied by physical , cognitive, and/or emotional symptoms including headaches, nausea, dizziness, depression, and slow processing. Factors that may impact recovery time include but are not limited to severity of injury, number of previous concussions and social support.

Evidence shows that limiting cognitive activity may have no positive effect on concussion healing time. In recent years much research has been performed to create new manag ement strategies for concussion, namely in ready to play (RTP) decisions. RTP guidelin es clearly specify when children should return to school, sporti ng or daily activities. Expert guidelines for concussion management include removing the patient from activity until asymptomatic, as to avoid any additional injury and allow for healing. Typically, concussion patients should seek follow up fr om their primary care physician. Ho wever patients with persistent or worsening symptoms (for example lasting longer than three weeks,) should seek consultation from a pediatric concussion specialist.

Resources:

  • O'Neill, J. A., Cox, M. K., Clay, O. J., Johnston, J. M., Jr., Novack, T. A., Schwebel, D. C., & Dreer, L. E. (2017). A review of the literature on pediatric concussions and return - to - learn (RTL): Implications for RTL policy, research, and practice. Rehabilitation Psychology , 62 (3), 300 – 323.
  • Arndt, D. H., Goodkin, H.P., Giza, C.C..(2015). Early posttraumatic seizures in the pediatric population. J ournal of Child Neurology , 1 - 4, 15 - 23.
  • Meehan, W.P., O'Brien, M.J. (2018). Concussion in children and adolescents: management. In A.C Hergenroader, R.G. Bachur, ed. UpToDate . Retrieved September 18, 2018 from https://www.uptodate.com/contents/concussion - in - children - and - adolenscents - management
  • KERRIGAN, J. M.; GIZA, C. C. When in doubt, sit it out! Pediatric concussion - an update. Child’s Nervous System: Chns: Official Journal Of The International Society For Pediatric Neurosurgery , out. 2017. v. 33, n. 10, p. 1669 – 1675.