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Children’s Head Injuries – When Do I Worry?
Kelly Ochoa, MD
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Right in Front of My Eyes
I look over to our dining table to see my 2-year-old standing there, right on top of the dining table, looking at me mischievously. She is definitely our “travieza” – Spanish for little troublemaker. Of course, instinctively, I scold her to get off the top of the table, but in a 2-year-old little independent girl’s mind, that means to stay on top. She then promptly starts sprinting across the table and steps right off the edge, falling headfirst onto the hardwood flooring. Head first!
She did not cry instantly, which is not good. I like crying after injuries, it means they did not lose consciousness and are responding appropriately to pain. So my heart starts racing as my pediatric ER doctor mind also races, and I run over to pick her up. She has a huge goose egg already forming on her forehead. She then starts crying (phew, good thing), but seems very out of it and sleepy, and not answering my questions. If I weren’t an ER doctor myself, we would’ve gone straight to the ER. But, rather, I held her and watched her over the course of the next half hour. She was sleepy but did not vomit. Eventually she was able to eat a little, took some Tylenol, and continued to improve. She had a concussion, but thankfully nothing worse!
What We Worry About With Head Injuries
Head injuries are so incredibly common in this toddler age as children explore their environment, learn the laws of gravity, and push their coordination limits. Head injuries are common, but serious brain injuries from them are not thanks to the very strong bone surrounding this most precious organ. So what thoughts were going through my mind as I held my little sleepy two-year old in my arms? When I evaluate a head injury in the emergency room, the very most pressing and urgent condition I need to make sure is NOT happening is a bleed inside the head. Since the skull is enclosed, if there is bleeding inside, there is no room for that blood to go, it starts pushing on the brain causing damage. If the bleeding is too much, it can cause part of the brain to be pushed lower down into the neck area. This is rare, but I’ve seen it numerous times, and it requires IMMEDIATE action.
What Signs Do I Watch For After a Fall?
So the next question is, how do I know if there is a bleed inside the head just by looking at the child and talking to the parent? How do I determine if a child needs imaging to look for a bleed?
When I evaluate a head injury I consider the child’s age – in children under the age of 2 I have a lower threshold to image. Did they lose consciousness when they hit their head? I clarify the mechanism of the fall (how high was the fall, onto what surface did they land, etc.). I look to see where the injury on the head is – forehead being the best, back of the head or over the temples being the most dangerous. How the child is acting after the fall is important – are they still dazed, are they vomiting, are they answering questions and interacting with me normally?
Usually, the symptoms we are looking for happen within 4 hours of the injury. We try not to image children, if at all possible, as imaging exposes the child to radiation that can increase a child’s risk of developing cancer in the future. If I see a child that I am worried about, I will typically watch them in the ER for 4 hours. If they vomit or I am concerned about developing signs of a brain bleed, I will then image.
CT Scan or Xray? ER or Urgent Care?
X-rays are not sufficient to evaluate head injury in children. The skull in children has many suture lines (still growing and developing), which can look like fractures on X-ray, and X-rays don’t evaluate inside the brain at all. If emergent imaging is necessary, we will get a CT scan, which unfortunately has more radiation, but will give us the information we need. Therefore, if your child needs imaging you will need to go to an ER, not an urgent care.
What If the Imaging Shows a Bleed or Fracture?
If imaging reveals a skull fracture, there really isn’t much we do about that – you don’t cast the head as we would other broken bones! We advise on limited activity (as much as possible in a toddler) to decrease any risk of repeat injury to that already damaged covering of the brain. If imaging reveals a bleed, even then, often we monitor, observe, and watch. Occasionally surgery is necessary, which will involve a brain surgery specialist.
What Else Do I Look For After a Fall?
Once I make sure I do not think there is any chance of bleeding in or around the brain going on, I then evaluate for concussion symptoms (see article to read more about concussions), or signs of a skull fracture. After that, I look for any other injuries that may have happened during the fall – dental, eye, or other body injuries.
In Summary For Head Injuries
Bottom line – if your little one has a head injury or fall, call your pediatrician for guidance. If it is after-hours, your child can be evaluated by an ER doctor at Health-e Pediatrics, to determine if imaging is necessary or if you are safe to let your child recoup at home. Of course, if your child is not acting right or vomiting after a head injury, do not delay and seek care in the ER.