Head Injury

Symptoms

DEFINITION

• Injuries to the head, including scalp, skull and brain

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Types of Head Injury

• Skin Trauma: Cut, scrape, bruise or scalp hematoma (goose egg)
• Skull Trauma: Fracture.
• Brain Trauma: Concussion and other brain injuries can be recognized by the presence of loss of consciousness, amnesia, or other Acute Neurological Symptoms.

Acute Neurologic Symptoms and Calling 911 - You should call 911 for any of the following acute neurologic symptoms occurring after a head injury:

1. Difficult to awaken OR
2. Confused or slow thinking and talking OR
3. Slurred speech OR
4. Weakness of arms or legs OR
5. Unsteady walking.

What is a Concussion?

• Definition: Confusion or alteration in mental status that follow a head injury. Loss of consciousness is not required.
• Symptoms: Unable to remember the injury, decreased ability to remember things in teh minutes-hours after the injury; confusion or "foggy" feeling; slurred speech; dizziness or incoordination; headache; nausea or vomiting.
• Diagnosis: The diagnosis is made by a doctor based upon the clinical examination of the injured person. A CT scan of a patient with a concussion (and no other brain injuries) is normal.
• Classification: See American Academy of Neurology (AAN) classification below.
• Return to Sports: See the AAN recommendations below.
• Prognosis: Most people who sustain a concussion recover and there is no signs of permanent damage. Sometimes a person can have concussion symptoms that last for weeks or months afterwards.

AAN Concussion Classification (American Academy of Neurology, 1997)

• Grade 1: Transient confusion; no loss of consciousness; concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes.
• Grade 2: Transient confusion; no loss of consciousness; concussion symptoms or mental status abnormalities on examination last more than 15 minutes.
• Grade 3: Any LOC, either brief (seconds) or prolonged (minutes).
• Note: All individuals with concussions need a neurological examination by a health care provider.

AAN When to Return to Sports Guidelines

• Grade 1: After normal neurologically for over 15 minutes
• Grade 2: After normal neurologically for 1 week
• Grade 3: After normal neurologically for 4 weeks
• Note: Multiple concussions require longer periods of recovery before returning to sports. The reason we sideline athletes who have a concussion is to prevent the "second impact injury". This is a second concussion that occurs within 1 or 2 weeks after the first one. The outcome can be catastrophic or even death.

Caution - Neck Injury

• The possibility of a neck injury should also be considered in all individuals with an injury to the head.
• Symptoms to be taken seriously include neck pain and arm or leg numbness or weakness.

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FIRST AID Advice for Bleeding: Apply direct pressure to the entire wound with a clean cloth.

FIRST AID Advice for Penetrating Object: If penetrating object still in place, don't remove it (Reason: removal could increase bleeding).

FIRST AID Advice for Shock: Lie down with feet elevated.

FIRST AID Advice for Suspected Spinal Cord Injury: Do not move until a spine board is applied.

Should I Call?

WHEN TO CALL YOUR DOCTOR

Call 911 Now (you may need an ambulance) If

• Persisting NEUROLOGIC SYMPTOM, any of the following:
  • Difficult to awaken
  • Confused or slow thinking and talking
  • Slurred speech
  • Weakness of arms or legs
  • Unsteady walking
• Seizure (convulsion) occurred
• Unconscious for more than 1 minute
• Neck pain occurring after head injury
• Penetrating head injury (e.g., knife, gun shot wound, metal object)
• Major bleeding (actively bleeding or spurting) that can't be stopped
• NOTE: For bleeding, see First Aid

Call Your Doctor Now (night or day) If

• You feel weak or very sick
• Had a NEUROLOGIC SYMPTOM that is now gone; any of the following:
  • Difficult to awaken
  • Confused or slow thinking and talking
  • Slurred speech
  • Numbness or weakness of arms or legs
  • Unsteady walking
• Knocked unconscious for less than 1 minute
• Blurred vision persists longer than 5 minutes
• Severe headache
• Can't remember what happened (amnesia)
• Vomiting
• Watery fluid dripping from the nose or ear
• Bleeding that won't stop after 10 minutes of direct pressure
• Skin is split open or gaping and may need stitches
• Large swelling
• Large dent in scalp
• Dangerous injury (e.g., MVA, diving, trampoline, contact sports, fall more than 10 feet) or severe blow from hard object (e.g., golf club or baseball bat)
• You are taking the blood thinner coumadin or have a history of a bleeding disorder

Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If

• You think you need to be seen
• Headache persists longer than 3 days

Call Your Doctor During Weekday Office Hours If

• You have other questions or concerns

Self Care at Home If

• Minor head injury and you don't think you need to be seen

Care at Home

HOME CARE ADVICE FOR MINOR HEAD INJURY

1. Treatment of Minor Cuts, Scratches and Scrapes (abrasions):
   • Apply direct pressure for 10 minutes to stop any bleeding.
   • Wash the wound with soap and water for 5 minutes.
   • Gently scrub out any dirt with a washcloth.
   • Apply an antibiotic ointment daily.
2. Treatment of Bruise or Hematoma ("goose egg"):
   • Apply an ice bag or massage the area with ice for 20 minutes each hour for 4 consecutive hours (20 minutes of ice bag massage followed by 40 minutes of rest for 4 hours in a row).
   • 48 hours after the injury, use local heat for 10 minutes 3 times each day to help reabsorb the blood.
3. Observation: The head-injured person should be observed closely during the first 2 hours following the injury. The head-injured person should be awakened every 4 hours for the first 24 hours; check for the ability to walk and talk. Mild headache, mild dizziness and nausea are common.
4. Diet: Clear fluids to drink at first, in case of vomiting. May resume a regular diet after 2 hours.
5. Pain Medication:
   • For pain relief, take acetaminophen or ibuprofen.
   • Acetaminophen (e.g., Tylenol): The dose is 650 mg by mouth every 4 hours or 1000 mg by mouth every 6 hours. Maximum dose per day = 4000 mg.
   • Ibuprofen (e.g., Motrin, Advil): The dose is 400 mg by mouth every 6 hours or 600 mg by mouth every 8 hours.
   • People who are over 65 Years of age: Acetaminophen is generally considered safer than ibuprofen. Acetaminophen dosing interval should be increased to every 8 hours because of reduced liver metabolism. Maximum dose per day = 3000 mg.
   • CAUTION: Do not take ibuprofen if you have stomach problems, kidney disease, are pregnant, or have been told by your doctor to avoid this type of anti-inflammatory drug. Do not take ibuprofen for more than 7 days without consulting your doctor.
   • CAUTION: Do not take acetaminophen if you have liver disease.
   • Read the package instructions thoroughly on all medications that you take.
6. Expected Course: Most head trauma only causes an injury to the scalp. Pain and swelling usually begin to improve 2 or 3 days after an injury. Swelling is usually gone in 7 days. Pain may take 1-2 weeks to completely resolve.
7. Call Your Doctor If:
   • Pain becomes severe
   • Neurological Symptoms (see above) occur during the next 3 days
   • You become worse

And remember, contact your doctor if you develop any of the "Call Your Doctor" symptoms.

Photo Example

First Aid - Bleeding Head

• Apply direct pressure to the entire wound with a sterile gauze dressing or a clean cloth

First Aid - Neck Injury

• Protect the neck from movement. Roll up towels (or blanket or clothing) and place them on either side of the head to keep the head from moving.
• Don't move victim until a neck brace is applied.

Notes:

• The Modified HAINES Position is preferable if the victim is vomiting or having trouble breathing. See: First Aid - Neck Injury (Modified HAINES)

First Aid - Neck Injury (Modified HAINES)

This position is termed the High Arm IN Endangered Spine or HAINES position.

Note that the this position has two significant differences when compared with the standard lateral recovery position:

• The arm closest to the ground is fully outstretched and lies under the head
• Both legs are flexed at the hip and the knee resulting in one lying on top of the other.

The modified HAINES position results in a more neutral position of the spine making it preferable to the lateral recovery position in the management of patients in whom cervical spine injury may have occurred.

Laceration - Scalp

This scalp laceration (cut) is gaping open. It will require closure with sutures or medical staples.

First Aid Care Advice:

• Apply direct pressure for 10 minutes to stop any bleeding.
• Wash the cut with soap and water.