Falling and hitting the head is very common. Studies show that
small children had to fall at least 3-4 feet to have internal harm
to the brain. That is waist high or grocery cart handle height.
There are four misconceptions of head injuries.
1. When the child hits their head, a goose bump comes up fast.
That is because there is a blood vessel torn below the skin
and it is bleeding below the scalp.
Ice will not help this. If you cut your leg and you are bleeding
bad from the cut, do you
put ice on it? No. You hold
pressure to clot the bleeding and stop it. What did you do the
last time you hit your head?
You pressed on it with your hand and
it made it feel better. So when the child hits their head, you do
not put ice on it.
You should hold your hand on it for 2
minutes to get the clot to form. It will make it feel better and there
will be only a
small bump instead of the big goose
egg. The child will be crying because he does not know what you
are doing but hold
your hand on it.
Also it does not
make a difference if the swelling goes out or not as to whether or not
there is a clot inside. There is an
old saying that if the swelling comes
out then it did not go in... but that has nothing to do with inside of
the skull. Small firm
goose eggs are usually not fractured
and large (big as your palm or bigger) mushy ones are usually a skull
fracture. Skull
fractures are not as important as
determining if there is internal damage or blood clot. You can
have serious internal harm
and no fracture.... and visa versa.
2. The child will frequently throw up once after a head injury
and crying. If they throw up 3 or more times then that is
significant.
3. It is OK to let the child go to sleep. Just wake them
up every hour during the night to see if you can rouse them. You
do not
have to "keep them awake".
4. The pupils are the last thing to change. When there is
damage from a head injury, first the child will become "drunk" acting.
Staggering slurring speech eyes rolling around drunk. Then
they go into a coma. Then their eyes change. The
pupils are for the ER doctor to use and not helpful for the average
person or parent to use.
So forget the ice, hold pressure, and bring them in immediately if
they are vomiting a lot and acting drunk.
Does your child need a CT scan?
There are certain indications for getting
a Cat Scan for head injuries. Trying not to expose children
at high radiation for CT scans.
An extensive study reported in the
Lancet. They enrolled and analysed 42,412 children. They
obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and
60 (0·1%) underwent neurosurgery. The prediction rule for children
younger than 2 years had a predictive value for normal scan was 100% and
the predictive value of positive CT scans was 100%.
1. normal mental status,
2. no scalp haematoma except frontal,
3. no loss of consciousness or loss of consciousness for less than 5 s,
4. non-severe injury mechanism,
5. no palpable skull fracture,
6. and acting normally according to the parents
The prediction rule for children aged 2 years and older
had a negative predictive value 99·95% normal scan and a 96.8 positive
predictive value of a positive scan.
1. normal mental status,
2. no loss of consciousness,
3. no vomiting,
4. non-severe injury mechanism,
5. no signs of basilar skull fracture, and no severe headache
Neither rule missed needed neurosurgery in validation
populations.
Dr. Knapp
p.s. Same for not ordering too many
chest x-rays. If the test will not change your medical decisions
or treatment, then avoid it the test. (Ditto for flu tests and
other tests)
