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Head Injury


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 (353%); ciTBIs occurred in 376 (09%), and 60 (01%) 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 9995% 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)