How to Know When Head Injuries Are Serious

By Celene McDermott August 29, 2016

It’s hard to believe that actress Natasha Richardson could fall on a bunny slope while skiing and be brain dead just hours later. As her death shocked the world, it has also increased awareness and worry among parents about brain swelling and bleeding when their child falls or gets hit in the head, whether it be while involved in sports or from any other kind of accident.

Dr. Robert Gochman, attending pediatric emergency medicine physician at Schneider’s Children Hospital-Long Island Jewish Medical Center, says that more parents are requesting CT scans, which provide an in-depth view of the brain to detect injury, skull fractures, and bleeding, when bringing their kids into the E.R. for head injuries. “We’ve looked at the numbers of CT scans in the couple of weeks after Natasha Richardson passed, and the numbers over the same period of time last year, and it’s 51 versus a dozen,” he says. “It’s very unusual. We’re calling it the ‘Richardson Effect.’”

While head trauma accounts for approximately 600,000 emergency room visits a year, along with 95,000 hospitalizations and 3,000 annual deaths in the United States (according to a 2001 study), the good news is that well over 90 percent of children’s head injuries turn out to be minor and do not require surgery. “It’s somewhat predicable who will develop problems and who will not,” says Dr. Gochman. “The kids who arrive at the emergency department with a large bump on their head and an abnormal exam (e.g. lethargic, irritable, acting abnormally or having problems seeing or walking) are at the greatest risk of having a significant bleed in their head.”

What Doctors Look For

If your child has any kind of head injury, an immediate medical visit is recommended. Doctors will look at these factors to help them determine the degree of risk:

The mechanism of the injury: A fall from five feet or more, a high velocity motor vehicle crash, hitting the head while falling off a bicycle without a helmet, or getting hit by a speeding baseball are more worrisome than your average fall with a bump to the child’s head.
The age of the patient: The smaller/younger the patient, the thinner the bones and the more difficult to assess how the child is feeling. All babies under 3 months should be seen, as it’s difficult to determine the extent of their injury.
Where on the head the child is hit: The back or front of the head is less worrisome than a blow to the side of the head.

“Patients who have no loss of consciousness and whose main symptom is a mild headache are at low risk for an intracranial injury and at very low risk for an injury for which a surgical intervention needs to occur,” says Dr. Peter Dayan, associate director of the division of pediatric emergency medicine at Morgan Stanley Children’s Hospital of NewYork-Presbyterian in Upper Manhattan. “The likelihood of any internal bleed in patients of minor accidents is less than five percent.”

The most common diagnosis of a head injury is a concussion, which Dr. Erik Larsen, associate director of emergency medicine at White Plains Hospital in White Plains, explains is a loose medical term that means that the brain has been rattled a bit. While many times a child will lose consciousness with a concussion, “Once someone’s lost consciousness for more than five minutes,” he says, “we’ve upped our worry level. And that certainly ups our intervention.”

At the emergency room, doctors will conduct a full evaluation and physical exam, and look for signs like amnesia or partial memory loss, testing the child to see if she is able to retain new information. They’ll also look for a previous history of head trauma and any kind of bleeding disorder, as well as signs of seizure, numbing, or weakness. They’ll conduct X-rays and CT scans when appropriate.

“There’s nothing like the power of observation,” says Dr. Larsen. “The vast majority of the time, symptoms are going to manifest themselves in the first four hours. In 24 hours, 99 percent of the time, you’ll find you don’t have a serious head injury. We like to hold onto patients for about four hours and make a decision as to whether they need to be admitted and see a neurosurgeon.”

Dr. Dayan agrees that patients with more severe intracranial injuries usually have symptoms that present themselves immediately or within a few hours after the incident. “It’s quite uncommon for there to be no symptoms, and then suddenly symptoms present themselves later,” he says. While there can be a lucid period when the child is awake and interacts, Dr. Dayan says that the patient is not symptom-free during this period, and will have symptoms that a parent would worry about, such as a progressive headache.

These symptoms can signify pressure building, which can come from bleeding or bruising of the brain. However, Dr. Dayan says, “The likelihood of needing an operation is quite low. Many times the bleeding stops on its own.”

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Possible Intracranial Injury

Following are symptoms of possible intracranial injury:

Immediate loss of consciousness
Seizure
No memory of the accident
Protracted vomiting
Marked irritability in younger kids
Severe pain/headache
A large hematoma, swelling, or goose egg on their head (but less so when this is on the forehead)
Pupils unequal
Weakness, dizziness or are walking strangely

“In Natasha Richardson’s case, she had an epidural hematoma (bleeding in a free space in the head) and these are a common form of bleeding in kids,” says Dr. Larsen. Dr. Gochman explains: “There is a large artery that runs along the side of the head. If you happen to crack your skull on that side, it’s not uncommon to crack this artery. With an arterial bleed, the artery has a fair amount of pressure; it closes space between the brain and the skull. What will happen is that space will accumulate with blood, bigger and bigger, eventually to the point that it squeezes the brain… The brain is pushed down into your neck through a very small hole.” This results in death.

In most cases, though, Dr. Dayan says that epidural hematomas are not fatal, and not as common as other types of bleeds, like a small cerebral hemorrhage. Very few of these hemorrhages in alert children (those who are not severely symptomatic), he says, need any type of surgery.

“If the injury causes only an epidural hematoma and the hematoma is evacuated promptly before the brain is “squeezed,” there should be no significant residual deficits,” says Dr. Gochman. “However, if the injury causes an epidural hematoma and a primary injury to the brain, there may be deficits even after the epidural hematoma has been evacuated.”

If you’re worried about your child, make sure to choose a hospital that has pediatric emergency specialists, Dr. Gochman advises. And if your child exhibits any warning signs of an intracranial injury, seek immediate attention. The first four to 12 hours are critical, he says.

“Generally, if a head trauma doesn’t manifest itself in the first 24 hours, you’re probably safe,” agrees Dr. Larsen. “The good news is, wearing a helmet during at-risk activities like skiing, bicycling, (and skateboarding) is an excellent way to prevent the head injury.”

Emergency Warning Signs in Babies and Children

Head Trauma

Seek medical attention for any kind of bump on the head or head injury, with or without loss of consciousness, in babies and small children. (See symptoms above.)

Fever

Fevers are probably the most common complaint in the E.R., according to Dr. Larsen. Most often, a child’s fever is caused by a viral infection that passes in two to three days. But, he warns, a high fever can signal meningitis or something more serious. For toddlers with a 102 fever, who are inconsolable, lethargic, not responding properly, not focusing, not giving a hint of a smile — “that’s not a good sign,” he says, adding that doctors are especially concerned when babies under 3 months old have a fever. That’s because infants don’t have the resilience to withstand a more serious infection, and can be easily dehydrated through fever and vomiting.

Seek help if:

The fever is 104-105°, it is the only symptom, and it persists.
The fever lasts five days, consistently.
The fever is 106° or greater.
The child is lethargic and barely makes eye contact, has persistent vomiting, diarrhea, rash or severe headache, and has any fever, regardless of the actual temperature.
An infant under 3 months has a temperature of 100.4° or more.
The child isn’t moving his neck.
A child, tween, or teen is getting sicker by the hour with the rapid onset of symptoms including headache, fever, vomiting, sleepiness, neck stiffness, and photophobia (it hurts to look at lights). These could be signs of bacterial meningitis, which can kill quickly. (A vaccine is recommended.)

Abdominal Pain

A low-grade fever combined with a high stomach pain that moves to the lower right, vomiting, and not wanting to eat or move are signs of appendicitis. The doctor may ask the child to jump up and down; if he doesn’t want to, it means the area is sensitive.

If you see your younger child (under age 2) holding her stomach, check to see if it’s tender (she’ll wince or cry).

Bleeding

Any kind of wound that doesn’t stop bleeding after applying direct pressure for 10 minutes should be seen. Also seek medical attention if blood is coming out of the child’s bottom, with or without poop. This will sometimes be accompanied by fever and abdominal pain or discomfort.