Head Injury

Dear Lisa,

My five year old daughter some how fell off a dining room chair and hit the bone directly above her eye. She immediately had a goose bump and bruising above her eye around to her eyelid. I immediately applied ice for about an hour and the swelling went down slightly. She showed no signs of being "out of it". She was suddenly tired. I managed to keep her awake for four hours.

Should I be concerned and call her pediatrician?

“Mother of accident prone child”,

Dear “Mother of accident prone child”,

Head trauma is a very common pediatric injury. Children are more likely to sustain injuries to their head as compared to adults for a few reasons. (1) First of all, the size and weight of a child’s head in much larger in comparison to the size of the rest of their body. The head is actually the center of gravity of a child’s body. This is why when a child has a fall; their head usually hits the ground first. In addition, a child’s level of coordination and reflexive responses are not fully developed. They do not have the ability to break their falls by putting their hands in front of them the way that adults do.

Head injuries are one of the most common causes of death and disability in the pediatric population. (2) The types of injuries that children experience as the result of a head trauma can range from something as minor as a simple scalp laceration to something as serious as a brain hematoma. Other injuries due to trauma to the head include; skull fracture, internal bleeding, Contusions and Lacerations of the brain. Problems can develop due to the fall itself or can be due to the pathological processes (such as swelling of the brain or lack of oxygen to the brain) due to the injury.

Deciphering the seriousness of a fall can be quite difficult when dealing with children. The symptoms of an intra-cranial injury due to head trauma vary greatly from one child to the next. An injury to the brain can occur without external evidence of injury or trauma. In some cases the symptoms are not displayed right away, but instead the symptoms can progress slowly or may occur hours later.

Infants and young children in particular can have this delayed presentation of symptoms. The deterioration of consciousness can occur hours after the incident, many times after what seemed to be a minor event. (3) This delayed presentation can represent a concussion, brain swelling, or intra-cranial hemorrhage. Therefore a parent can never be too careful when it comes to seeking medical attention when a child experiences a head injury. Children with head trauma should be monitored closely over a period of hours. In many cases, repeat examinations by a health care professional are needed.

Skull and brain injuries are much easier to diagnose when a child presents with obvious symptoms. These obvious symptoms include loss of consciousness, seizure activity or apnea. (4) On the other hand, younger children with milder, non-specific signs may go unnoticed. These non-specific symptoms include irritability, recurrent vomiting, fever and loss of appetite. (4) Since any young child can experience these non-specific symptoms on any given day for a variety of reasons, an examination by a health care professional is necessary in order to determine the cause of the symptoms.

Skull fractures are one of the types of injuries that can occur due to head trauma. A skull fracture may occur at the site of impact or in other areas of the skull with less strength. Some skull fractures are associated with Cerebral Spinal Fluid leaks or cranial nerve injuries. (2) Therefore any question of a skull fracture should be evaluated in an Emergency Room setting.

The Battle sign and “raccoon eyes” are two findings associated with a basilar skull fracture, one of the most serious types of skull fractures.(2) The Battle sign is the presence of bruising (a black and blue) behind the ear. The term “Raccoon eyes” refers to bruising and swelling around the eyes. Both of these signs after a head trauma are worrisome signs that need to be evaluated by a Physician without delay.

A concussion is a clinical syndrome causing immediate and transient impairment of consciousness following a head injury. Children who develop a concussion may experience visual disturbances, loss of memory, loss of appetite, pallor, vomiting, sleepiness, confusion, abnormal behavior, unsteady gait or coma. The duration of symptoms may vary from days to weeks and range in severity from mild to severe. In some cases a delayed presentation may occur, therefore a child with a head injury needs to be monitored for a concussion for hours after the actual injury.

Cerebral Contusions, Lacerations, and Hemorrhage are very serious complications that can result in significant morbidity and in some cases mortality or death.

A child who develops irritability, ataxia (unsteady gait), vomiting, loss of appetite or change in mental status after an injury to the head should be examined by a health care professional. Since your daughter became suddenly tired you need to contact her Pediatrician. Besides the concern for a concussion, an injury to the orbit(bone around the eye) or the eye itself also needs to be ruled out. The orbit can fracture in children who land on their face or in children that have a ball or object thrown at their eye.

It is important to know that not every child who becomes tired or irritable after a fall has a serious brain injury. In some cases a child becomes irritable because of pain due to a fall. Children can become tired after a fall because it is their usual bedtime or time to nap. They also may have become exhausted from all of the excitement and activity after the injury.

In regards to vomiting, one or two episodes of vomiting within the first couple of hours of trauma is often associated with mild head injury. (3) On the other hand, persistent vomiting or vomiting in association with somnolence can represent a more serious situation that needs to be evaluated without delay.

It is best to let the Physician determine the cause a child’s symptoms rather then guess and wait for the symptoms to worsen. Waiting can worsen the situation and result in secondary injury to the brain. In addition, it is important that you inform your Physician about falls resulting in injury to your child's head, even if they seem minor.


References:
(1)Bautista S, Flynn J. Trauma Prevention in Children. Pediatric Annals. 2006. 35(2):85-90.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1801-1803.
(3)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:621.
(4)Hymel K, Hall C. Diagnosing Pediatric Head Trauma. Pediatric Annals. 2005. 34(5):358-370.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Childhood Safety