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Head Injury

If you are reading this because your child has injured his/her head, READ THIS PART FIRST. If your child:

• is unconscious or sleepy and hard to awaken or arouse
• is vomiting repeatedly
• is having trouble walking normally (if s/he is old enough to walk)
• is not recognizing you, or seems to be getting more confused
• has blood or clear fluid coming out of the nose or ears
• has a bad headache
• has pupils of different sizes
• has a head injury under which you can feel a "step" in the skull bones

Children who have bumped their heads -- in whatever way, and for whatever reason -- are among the most common visitors to pediatricians' office, after-hours clinics, and emergency rooms. In some cases the resulting head injury is serious, and the child needs immediate treatment. In others, a child may have to be observed in the emergency room or the hospital for a while to make sure that there will be no late-appearing problems. In some cases, though, you as parents can watch the child at home, as long as you know what signs to watch for that indicate that your child needs to be seen by the doctor. The safest thing to do if your child has bumped his/her head is to call your doctor and describe the injury and how your child is acting. Your doctor can then give you more specific advice on what to do and what to watch for.

Open Head Injuries

Common sense should tell you what to do here. An injury that has damaged the skin of the scalp, whether or not the skull has been damaged, should be examined in the emergency room. Small tears in the skin may not need any more treatment than a bandage, but large lacerations may need to be sutured. (Actually, many of us close scalp lacerations with surgical staples, which are easier and faster to put in and easier and faster to take out. They do tend to leave more of a scar than stitches, but under a full head of hair the scar doesn't matter. And no, the staples do not go into the skull...)

Closed Head Injuries

When the skin has not been broken by the injury, it's a little harder to decide how bad the injury is. In these cases, unless the description of the injury makes me believe that the injury is minor and the child is acting completely normally, I tend to err on the side of caution and ask the parents to bring the child in to be seen, either in the office or in an After-Hours Clinic. The questions I ask when I'm deciding whether to see the patient include:

• If the child is old enough to tell us what happened, does s/he remember getting hurt?
• If the child is not old enough to talk, did s/he cry immediately when the injury occurred? (These tell us whether the child lost consciousness with the injury. If I suspect loss of consciousness I insist on seeing the child, and am more likely to want to get advanced tests like a CT scan of the head. Some doctors will examine children only if they have been unconscious for more than 60 seconds, but I prefer to examine a child if there is any suggestion of loss of consciousness, since often you can't really figure out how long someone was unconscious.)
• Is there blood or clear fluid coming out of the nose or ears, or is there a bruise below an ear? (These may be signs of a fracture at the base of the skull, or in the part of the skull that separates the air passages of the nose from the front part of the brain.)
• Can you feel a "step-off" under the skin where the head was hit? (This happens when the skull is fractured and the pieces are displaced. Linear skull fractures, where there is a simple crack without movement of the bones, are much less serious -- in fact, linear fractures are usually not repaired, since they heal better if they are left alone than if they are fixed surgically. A displaced fracture, on the other hand, may mean that the brain tissue under the fracture has been damaged by the pieces. That needs to be checked.)
• Is the child behaving as s/he usually does? (Changes in behaviour, such as sleepiness, may occur even with minor head injuries in the first half hour or so. However, if the changes last longer or are getting worse the child must be examined.)
• Are the pupils the same size, and do they become smaller when you shine a light in the eyes? (If they are not, there is a very good chance that the brain has been injured. However, changes in the way the pupils behave tends to happen later in the course of head injury than some of the other signs.)

When I examine a child whose head has been injured, I usually pay attention to the signs I've listed above. I do a complete neurological exam as well, to look for other signs of brain injury. We probably do far more CT scans on children who have bumped their heads than we should be doing; a study published in The Lancet, on September 15, 2009, suggests that a child (younger than age 18 years) with a head injury, who is less than 2 years old and

• is acting normally, according to the parents
• did not lose consciousness for more than 5 seconds
• no hematoma (bleeding under the skin with swelling) of the scalp, except possibly on the forehead
• does not have a step-off or another palpable (something we can feel with our fingers) skull fracture
• does not have signs of a fracture at the base of the skull, and
• was not "severely" injured, meaning that she was
  • not in a car accident in which someone was thrown out of the car, someone was killed, or the car rolled over
  • a pedestrian or on a bike without a helmet, and hit by a car or truck, OR
  • fell more than 3 feet

• is acting normally, according to the parents
• does not have a severe headache
• did not lose consciousness with the injury, or did not black out for more than 5 seconds if the child is less than 2 years old
• did not vomit after the injury
• no hematoma (bleeding under the skin with swelling) of the scalp, except possibly on the forehead
• does not have a step-off or another palpable (something we can feel with our fingers) skull fracture
• does not have signs of a fracture at the base of the skull, and
• was not "severely" injured, meaning that she was
  • not in a car accident in which someone was thrown out of the car, someone was killed, or the car rolled over
  • a pedestrian or on a bike without a helmet, and hit by a car or truck, OR
  • fell more than 5 feet when injured

• Look at your child every one hour for the first 8 hours, then every two hours for the next 16 hours. If s/he is asleep, wake him/her up.
• When you look at your child, make sure that s/he wakes up and knows who you are.
• If s/he is old enough to walk, make your child walk around the bed once or twice at each check, and watch to see that s/he is walking properly.
• Shine a flashlight in each eye and make sure that the pupils become smaller.
• If any of these signs are not normal, call or bring your child to the ER.

This sounds -- and is -- pretty time-consuming, but it may be a lot better than spending 24 hours in the hospital. Usually, if there are no problems in the first 24 hours after an injury, the child will be fine. Occasionally, there may be a problem that crops up later, but keeping an eye on your child and calling your doctor if any changes occur should guard against any late effects of the injury.

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Copyright © 1998, 1999, 2000, 2005, 2007, 2009 Vinay N. Reddy, M.D. All rights reserved.
Written 04/12/98; last revised 09/21/09