Friday, February 5, 2016

Head Injuries (update)


I can safely say that not a week goes by at work when I don't get the call. The mom or dad is in tears as they recount in horror that their baby just fell. Sometimes they left the baby on an unprotected surface for a moment, not imagining that the infant could manage to roll off. That thud is an awful sound. Sometimes they are right there watching it happen, but can't move fast enough to catch them. Once in awhile a baby is accidentally dropped (watch out for wet, squirmy babies right out of the tub.) Sometimes a parent falls when holding the baby and they both get injured. Recently I have even seen a new cause: Selfie accidents! Mom or dad holding the phone way out for a photo op, and not having a good grip on the baby. Head plops backwards...

There are so many scenarios.

My husband came pretty close to dropping Lauren, our first born when she was very young. He just barely caught her by grabbing the bottom of the sleep sack that she was wearing. He had nightmares about that one for awhile.

I actually remember in my own case, what I describe as the definition of absolute ambivalence. My four year old Alana had a friend over and they were playing upstairs. I heard the unmistakable sound of someone tumbling down the steps. As I ran to the scene I recall thinking, "who do I want that to be? My child or the friend?" It turned out that it was my kid. They had been playing dress-up and she was wearing a pair of high heels (Satan's shoes.) She stood up with a giggle and brushed herself off, but it took me a moment before I could take a breath and then we made a new rule about dress up shoes and steps.

The fact is that most of the time that kids are indeed fine following a mild to moderate fall.
I think that younger children are like cats. Instead of tensing up when they fall, they remain relaxed until they make contact and for that reason they avoid getting more injured.

Of course it isn't just babies who fall. Children and adults have accidents and sports injuries all the time.   

If your baby just fell or you are the first responder at any kind of accident, take a deep breath. You need to remain calm. You can have a glass of wine later.  

If there is a loss of conscience or any possible neck injury, CALL 911.

Most of the time your child will be crying after a moment or two of stunned silence.
Do a quick head to toe assessment. Is there any obvious bleeding, bruising, sprains or fractures that need to be tended to? Check the mouth and make sure there are no loose teeth (this is the reason that you already have a relationship with a pediatric dentist...(Dental blog post)

If your child will let you, get a cold pack on any bruises. If you are out of the house, a cold can from a vending machine is a good option. If you are home, a bag of frozen peas makes a nice ice pack. For toddlers and preschoolers, playing doctor before anything happens and letting them know that after a bump we put on the cold pack may help them be more willing to let you put anything on there after an injury.There are some cute little pediatric friendly cold packs available that might elicit cooperation.

I also have had good results with the use of Arnica. Arnica is a homeopathic treatment that comes as a topical ointment or little pellets that are taken by mouth. Many parents swear that it significantly decreases bruises (roll  your eyes if you must, but I have seen it work.) It is worth having some around.

Be aware that head wounds can create a huge amount of blood if there is even a tiny little break in the skin. If the skin remains intact, all of that blood can collect into an enormous goose egg. These can get big, fast! These can look fairly alarming and can turn all sorts of lovely colors, but they do resolve. Bruises and bumps by themselves are not typically a concern.

But, now comes the scary part. We are much more focused on any bleeding that might be happening beneath the skull. If there is bleeding under the skull, there is little room for any swelling. This could cause potential pressure on the brain. Typically we would be alerted to the fact that this is happening by your child's behavior. We want to pay attention to any vomiting, sleepiness, fussiness or dizziness.

I actually give the kids "one free vomit". Often they have cried hard enough that they might spit up a little. Let's not worry about that first emesis. If they vomit a second time, they need to be seen. Note that Murphy's Law pays close attention to these scenarios and your child could be coming down with a tummy bug that has no relation to the fall.

You may have heard the adage that following a head injury you should not let someone fall asleep. This comes from the fear that someone with a significant head trauma could go into a coma and if not monitored would simply not wake up. Granted, in the rare, worst case scenarios this is indeed true, but I have never had that happen to any of our patients (and remember this is a very frequent call!) If your child calms down and seems to be acting okay, let them take their normal nap. Face it, without a nap, your little one will be cranky and falling asleep and may be near impossible to assess. Don't let them take a 'super nap'. Wake them up after two hours. Depending on how far and hard they fell, I would check on them every couple of hours during the night. You can set your clock to make sure you get up to do this.

With an infant you can offer them a dream feed. They don't need to be fully roused.
With an older child, let them know you will be asking them for a "magic word" during the night and when you come to them they simply need to say whatever predetermined word or phrase such as "I love you" and then then can go back to sleep. You are simply establishing consciousness; you often don't need to wake them completely up.
Keep in mind that if your child is in a deep sleep stage, a gentle whisper might not be enough to wake them up. For older kids, if they know ahead of time that you will be coming in, they are easier to wake up.

Pupil changes would be of immense concern but would happen only with a serious injury and would NOT be the only symptom. Some folks, as their baseline, have pupils that are not exactly the same size. They were born this way but no one noticed. I would suggest checking your child's eyes before they fall so that you don't get freaked out if they seem off to you after a fall if you are noticing that for the first time.  

After a solid knock to the head you are not out of the woods the next day. Any dizziness or headaches that occur within a week or two following the head trauma need to be paid attention to.

If your child has a concussion, it is critically important to avoid another head trauma within the next couple of weeks. There is a something called Secondary Impact Syndrome that can occur when this happens . In this case one plus one does NOT equal two.

Please exercise common sense precautions to avoid being the person who has to call about a fall, but remember that most of the time it is harder on the traumatized parent than it is for the patient. Accidents happen to even the most vigilant care giver.

If you call, we will want to know:

  • How far do you think they fell?
  • What kind of surface did they fall onto?
  • What was the immediate reaction?
  • How long did it take until they stopped crying?

A basic neurological exam might include the following (of course some of these are age dependent):

  • can they answer simple questions?
  • Is there any complaint of blurry vision
  • Do the pupils react to light at the same speed (generally if a penlight is shined into the eyes, the pupil will get smaller)
  • Can they touch their finger to their nose? Do this with each hand.
  • Is there any clear drainage from the nose or ears? (Murphy's Law again. What toddler doesn't have a runny nose?)

If they are assessed and there is concern, the next step is generally an imaging study (CT scan.) This is a valuable option when it is genuinely needed, but if your child looks good, I would hesitate to put your child through the stress, expense and radiation.

Stay safe!


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