Posttraumatic seizures are divided into one of three patterns: impact seizures, early posttraumatic seizures, and lateposttraumatic seizures. Impact seizures occur within secondsof the injury and are presumed to reflect a direct mechanical stimulation to the cortex. The prognosis is excellent, andlikelihood of later epilepsy is negligible. Early posttraumaticseizures occurring within the first week of the head injury arelikely the result of a localized area of cerebral contusion or edema. The long-term prognosis for these seizures is quitefavorable. Late posttraumatic seizures arise more than a weekafter the trauma and most likely indicate an area of corticalgliosis or scarring that will be a source for long-term epilepsy.These patients often require long-term antiepileptic drugtherapy.
Transient neurologic disturbances may develop a few minutes after head trauma and last for minutes to hours before clearing. The most common symptoms are corticalblindness and confusional states, but hemiparesis, ataxia, orany other neurologic deficit may appear. These symptomsmay represent a trauma-triggered migraine in susceptiblechildren, but care must be exercised to exclude intracranial pathology.
Drowsiness, headache, and vomiting are common after head trauma. They are not, by themselves, of concern if consciousness is preserved, the clinical trend is one of improvement, and results of the neurologic examination are normal. Children are especially susceptible to somnolence after head trauma but should be easily arousable. If symptoms worsen or persist for more than 1 to 2 days, neuroimaging may be indicated to look for subdural hematoma or cerebral edema.
Children who have been unconscious or have amnesia following a head injury should be evaluated in an emergency department. High-risk patients include those with persistent depressed or decreasing level of consciousness, focal neurologic signs, penetrating skull injury, depressed skull fractures, or worsening symptoms. Because patients with intracranial hemorrhage may progressively deteriorate and require immediate neurosurgical care, these patients warrant care in a skilled trauma center.
The Glasgow Coma Scale is a valuable tool for monitoring the course of patients after trauma for signs of deterioration (Chapter 42). Management includes ensuring an appropriate airway, breathing, and circulation. Neuroimaging with CT or magnetic resonance imaging (MRI), and skull and cervical spine radiographs are obtained emergently. Neuroimaging is not necessary for uncomplicated concussions but should be employed whenever suspicion of structural intracranial lesion exists.
The observation period varies with the severity of the injury and may include hospitalization even for children without neurologic deficits who have sustained a concussion. Any patient demonstrating any features of a concussion should be medically evaluated, and disposition (return to play) must be determined by a health care provider (see Table 184-3). The child should be monitored for deterioration over the initial few hours after injury and not left alone. If the child appears well after several hours and is discharged home, parents should be instructed to call their physician for any change in alertness, orientation, or neurologic functioning. An increase in somnolence, headache, or vomiting is cause for concern and neuroimaging.
Patients with intracranial hemorrhage may require emergent surgical intervention for decompression and drainage of the blood collection. Increased ICP may require monitoring, placement of a ventricular drain, and aggressive medical management, including intubation and ventilation, osmotic therapy, and sedation (see later discussion).