Head Injury
Head injury is a complicated subject because often the result is an injury to our most complicated organ – the brain. Let's take a look at some of the problems that can result from a head injury. We are going to ignore important problems like facial injuries, injuries to the teeth and jaw, cosmetic injuries including fracture of the nose, and neck injuries.
The least important injury is a skull fracture. There is actually no treatment for a skull fracture unless an entire section of bone is pressed inward (a depressed skull fracture). A doctor may suspect a skull fracture, but there is no need to do an x-ray because it is just unnecessary radiation since the x-ray result would not change the treatment. It is more important to evaluate brain function. Imaging that looks at the brain may incidentally identify a skull fracture, but it is the effect of the injury on the brain that is most important.
In the aftermath of a head injury there is a need to evaluate two very important problems. One is concussion. The other is increased intracranial pressure. Let's look at that second problem since it is not well understood by most non-medical people. The brain is surrounded by fluid to protect it from changes in pressure as we go about our daily tasks. In fact, the brain is very sensitive to pressure, and does not function normally in situations in which something is pushing against it. The skull, also known as the cranium, is bony and not very flexible, particularly in children over the age of two. Everything inside the cranium is considered to be intracranial. If the brain swells or bleeds as a consequence of trauma, the pressure of the blood or bone against the brain leads to acute symptoms. There may be vomiting, and an inability to communicate or stand. One pupil may appear larger than the other because of the pressure on one side of the brain. Eventually unconsciousness occurs. In the absence of treatment death can occur. Obviously it is very important to seek medical attention if someone hits his head and has a deterioration of his mental status.
A concussion is another problem entirely. Unfortunately, it can sometimes be difficult to know immediately after a head injury whether there has been a concussion or the development of increased intracranial pressure. Small children especially may vomit after a head injury, but recurrent vomiting is a reason to get help immediately. If someone after having a head injury seems “out of it” and not able to respond appropriately, but is otherwise stable, he may have a concussion. So what is a concussion? A temporary jostling of the brain that leads to some loss of normal function is the simple definition of a concussion. Unlike increased intracranial pressure, there is no acute treatment for a concussion. Whereas increased intracranial pressure may lead to coma, concussion may lead to drowsiness. People often think that you should not let someone with a head injury sleep, but this is a misunderstanding. You can't prevent a coma by trying to rouse a person, but a person with a concussion should be allowed to sleep. You should gently rouse the patient every hour or so to gauge the response, but there is no reason to prevent him from sleeping. The reason that people with head injuries are brought to the hospital for CAT scans is to evaluate for increased intracranial pressure. There is no imaging test that will identify a concussion.
The treatment of a concussion requires both rest with a reduction of stimulation (like electronic devices and television) and a slow increase in activity. The details must be individualized and should be left to the doctor who will regularly evaluate the patient. Sometimes, but not always, a neurologist will be asked to consult. Medication is sometimes used for post-concussion syndrome, a situation where dullness, loss of balance, and headache may persist for weeks or months.
Not surprisingly, the best treatment for head injury is to try to prevent one in the first place. Make sure everyone in the car wears a seat belt. Require helmets for everyone riding – whether a bike, a scooter, a skateboard, skates, skis, or a snowboard. If you can fall off, you should wear a helmet.
Robert B. Golenbock, MD