The Fragility of the Brain
Maybe I’m stating the obvious, but the brain is a very delicate organ. The body is designed to protect this soft structure with a hard, protective covering (the skull). But, despite the body’s attempt to protect this fragile structure, the brain can still be subject to injury from significant traumatic events.
While most traumatic events involve a direct impact to the head, some can involve acceleration/deceleration injuries that involve the brain striking the inside of the skull or shearing forces that disrupt the integrity of the neuronal tissue of the brain. The results of the traumatic event to the brain can involve swelling or bleeding of the brain tissue that, in turn, can result in mild symptoms to life-threatening symptoms. So, how is a parent to know how severe a head injury is and when to seek medical attention?
The Pressure Problem
In order to know how severe a head injury is, one must understand that one of the main concerns about brain injuries is that the hard, protective bone of the skull which is meant to safeguard the brain tissue creates a firm, closed container. One could compare the situation to a crowded room with insufficient space for everyone. Imagine if you and your friends were all in a small room, and more and more people kept coming in until it was really crowded. The walls of the room would start to push against you, and you might feel uncomfortable or even pain.
Regarding the brain, if there is significant swelling or bleeding, there is not much space for the brain tissue to expand or move within the skull. This limited space for the brain tissue to expand or move with bleeding or swelling will cause an increase in pressure within the skull and damage the brain further, under the condition of significant brain swelling or bleeding. This is the worst-case scenario because this extreme situation can result in significant brain injury and even death. Luckily, a vast majority of head traumas do not have this outcome. Most injuries that we tend to see in the urgent care setting are minor, but we must always be on the lookout for injuries that require more thorough evaluation or monitoring.
Identifying Mild vs. Concerning Head Injuries
Young children striking their heads while falling into walls or onto the ground while running, older children getting struck in the head by a hard object like a baseball or colliding heads with another child during sports, or an infant striking their head upon falling off a bed or couch onto the floor are common scenarios that initiate visits to the urgent care or emergency room for further evaluation. So, the question remains; how do you differentiate a mild head injury from a more concerning head injury? Well, the Pediatric Emergency Care Applied Research Network (PECARN) set out to look into this issue. They identified mechanisms of injury and signs/symptoms that put a child at low risk for a severe head injury and created the PECARN Pediatric Head Injury Prediction Rule to allow physicians to safely rule out the presence of clinically important traumatic brain injuries.
According to these rules, the following exam findings, symptoms, and mechanisms of injury suggest a higher risk of clinically important traumatic brain injury requiring acute interventions, and a head CT scan should be considered.
Children Younger Than 2 Years of Age
- Glasgow Coma Scale Score (GCS) < 15
- Palpable skull fracture
- Altered mental status (agitation, somnolence, slow response, repetitive questioning)
- Scalp hematoma (excluding frontal)
- Loss of consciousness > 5 seconds
- Not acting normally per parent
- Severe mechanism of injury:
- Fall > 3 feet
- Motor vehicle accident with ejection of the patient, rollover, or fatality (of other passenger in the vehicle)
- Bike or pedestrian without helmet vs vehicle
- Struck by high-impact object
Children 2 Years of Age and Older
- Glasgow Coma Scale Score (GCS) < 15
- Signs of basilar skull fracture
- Altered mental status (agitation, somnolence, slow response, repetitive questioning)
- Vomiting
- Loss of consciousness
- Severe headache
- Severe mechanism of injury:
- Fall > 5 feet
- Motor vehicle accident with ejection of the patient, rollover, or fatality (of other passenger in the vehicle)
- Bike or pedestrian without helmet vs vehicle
- Struck by high-impact object
Furthermore, other low-risk injuries include ground-level falls and running into stationary objects. However, special considerations should be applied to children with underlying medical conditions or medications that may predispose them to bleed within the head (i.e., hemophilia and taking anticoagulation medications).
When to Seek Medical Attention
As a parent, if you are assessing your child’s symptoms at home after he or she sustains a head injury, seek medical attention if your child:
- Had a seizure after the accident
- Passed out after the injury (loss of consciousness)
- Is confused or hard to wake up
- Has a headache that is getting worse and does not go away
- Complains of new vision changes or one pupil (the black part in the middle of the eye) that is larger than the other pupil
- Has slurred speech, balance problems, or decreased coordination
- Suffers from new or worse vomiting
- Seems less alert
- Has new weakness or numbness in any part of the body
- Develops new symptoms, such as a headache, trouble concentrating, or changes in behavior
- Does not get better as expected
However, if you are at all concerned or have any questions about your child’s head injury, reaching out to your pediatrician, local pediatric urgent care, or emergency department is always encouraged.
Be Safe
Childhood head injuries can be quite distressing for parents. While the body is built to withstand most injuries to the head, the brain is still a fragile organ that requires special care and attention. Most head injuries do not result in severe consequences. Nevertheless, knowing what type of injuries and symptoms constitute worrisome findings is important. Again, I may be stating the obvious, but when it comes to the brain, it is always better to be safe than sorry.
What are some misconceptions about childhood head injuries that you’ve come across, and how can we educate parents and others to avoid them?
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