Most of us have visited the local emergency department for one thing or another. Whether bringing your elderly neighbor to the ER after a fall, or having your child evaluated after a hard hit on the football field, you'll probably visit the local urgent care or emergency department at least twice in your life. Periodically in the news we hear of famous persons dying after a head injury. As a result of the media hype, my ER along all of the others in the United States see an immediate spike in emergency room visits for minor head trauma from fearful patients. That's ok with me, as part of my job is to give you peace of mind as well as to tell you that your not going to die from that little bump on your head.
But when a head injury occurs, when should you go to the ER and what should you expect? How do you know if its really a "serious" head injury? Everyone knows that ERs are expensive and crowded, and sometimes the wait to be seen can be 4-6 hours. No one wants to waste time and money, but if your child falls and bangs his head on the coffee table, and you see a growing purple lump on his head, what else are you going to do? Does he need to go to the ER for a X-rays or Cat Scan? Here are some points to consider when deciding whether you need to rush to the ER or not.
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Is there a laceration? If there is any wound on the face, you should go. This goes for lacerations as well as periorbital trauma (trauma to the eye sockets) and nasal or oral trauma. Scalp lacerations smaller than 3mm can usually be managed at home if there isn't significant bleeding.
What was the mechanism of injury? The vast majority of head injuries come from falls where the head strikes the ground, table or some other inanimate object. Don't let this variable dictate whether you go to the ER or not. The height of the fall, or speed of object striking a person, is not a dependable indicator of potential underlying injury. When in doubt, go see a doctor.
Is there a concussion or brain injury? This is the million dollar question and the real purpose behind this article. While lacerations and moderate facial trauma may affect some cosmetic and functional outcome, a true brain injury or brain bleed, can cause death or a significant life long disability. So how can you tell if this is occurring? Let's begin with a simple definition of a concussion. A concussion is simply an injury that occurs to the brain from a blow to the head. The brain literally gets rattled around in the skull and can cause bruising of the brain, or worse, axonal shearing which can be thought of as your nerves literally being torn in half. Symptoms of concussion can range from mild dizziness and headache to severe vertigo and vomiting with confusion and inability to walk or remember events. Either way, in most cases is a concussion is a condition in which the patient fully recovers with little or no lasting effects. The tricky part in declaring that someone has a concussion lies in the fact that there is no test for most mild to moderate concussions. No black and white labs or imaging that will tell you a person is concussed. It is strictly a clinical judgement by looking at the symptoms, and if the symptoms are severe enough, you must consider and investigate the possibility of a more head serious injury.
A brain bleed on the other hand is an immediate medical emergency. Blood streams into the cranium putting pressure on the brain. The brain is then literally forced down into the foramen magnum, the hole where your spinal cord exits the skull. The result is that the cerebellum, the area of your brain responsible for spontaneous respiration and cardiac function, literally gets smashed through the foramen magnum, killing the patient. As expected, a patient with a brain bleed first experiences a severe headache and vomiting, then stiffness of the neck and other neurological symptoms similar to stroke, and finally death. If the patient doesn't have any significant symptoms after the first few "golden hours", chances are better that they have a simple concussion and not a bleed.
Do I need a Cat Scan? A lump on the scalp is like a bruise that swells underneath the scalp, but above the skullbones. It doesn't mean there is bleeding inside the cranium. But since bleeding inside the brain case can be so serious, we often obtain a computerized set of x-rays call a CT Scan. The medical standard of care for CT scans in head injuries is basically this: If the patient was knocked unconscious or there is a suspicion of an intracranial bleed or fracture, a CT scan is necessary. So you can see there is some wiggle room for the personal judgment of the medical provider. Keep in mind though, studies show that during a single head CT exam, a person's brain is exposed to the equivalent of up to 300 Xrays! When I order an CT of the brain and skull, I have high suspicion of true injury (or high suspicion of liability I'm sorry to say!). With that in mind, if the patient doesn't have brain bleed symptoms, a CT scan is not warranted as the exposure to high doses of radiation increases the chances of cancer and other complications.
So what's the bottom line? How do you know if you need to go to the ER? Look at the entire situation and make your decision. Basically, if there is nothing to fix like a laceration or broken bone, and the patient denies having a significant headache, and is walking and talking as usual, they probably don't have an intracranial bleed. If you're not sure however, go see the doctor! It's a judgement call on your part and no one will blame you for erring on the side of caution. You can never be too careful and as I said before, my role as a trauma PA is not only to treat patients and prescribe medicines, but also to set your mind at ease that your going to be ok.
Head Injury and Concussion - How to Tell If It's Serious and When to Go to the ER!
Richard Fan is a practicing emergency/trauma physician assistant in a busy Southern California ER, and an medical officer on the national disaster response team, DMAT CA-1. Please visit Smart Life Store where you'll get unbiased opinions and reviews about the latest in Tasers and Nannycams units.
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