 INJURY
A thumbnail
guide to children's head injuries, cuts, bleeding, and stitches
By Philip H. Chamberlain,
M.D.
Copyright 1995 by Parents' Press
No matter how
many precautions careful parents take, children still manage
to get hurt quite regularly. It seems that a certain number of
falls, bangs, cuts, and bruises are part of growing up.
Here are some
guidelines for evaluating head injuries, stopping bleeding, and
deciding if a wound needs stitches.
THE BIGGEST
WORRY: HEAD INJURIES
Nothing causes
as much fear and anxiety for parents as a possible head injury.
Hardly a day passes in our office without a call from a worried
parent whose child has suffered a bang on the head.
Head injuries
occur at all ages. Falls from the crib, a changing table, the
parents' bed, high chairs, and even someone's arms are common.
I frequently see distraught parents who have tripped and fallen
while carrying their baby. I have seen two cases where infants
suffered skull fractures because the baby suddenly arched his
back and flipped out of someone's arms and onto a hard surface.
When children
are learning to walk, head injuries usually result from rather
short falls to the floor. As children grow more mobile and adventuresome,
they are more often injured by doorknobs, window sills, fireplaces,
falls down stairs or onto sidewalks, or baseball bats. Thrown
balls and rocks can cause sharp injuries.
Fortunately,
an infant's skull is not the closed bony box it eventually becomes
in children and adults. The top of a baby's skull is made up
of five main plates of bone, which "float" over the
surface of the brain. This allows the skull to expand and accommodate
the rapid growth of the infant's brain. A layer of fluid between
the skull and the brain, called cerebrospinal fluid, provides
a cushion that also protects the brain.
At a 1995 conference,
I heard a report on injuries from falls seen over a ten-year
period in the Emergency Department of Chicago's Cook County Hospital,
one of the busiest emergency rooms in the country. It was comforting
to me (and it should also be comforting to parents of forever-falling-down
children) to find that very few serious injuries were found in
kids who fell from a height of less than six feet.
CASE HISTORIES
Let me give you
a couple of case histories to illustrate the wide range of symptoms
and findings in cases of head injuries. Hopefully, these fictitious
cases will help you evaluate head injuries you may encounter
in your own children.
A TYPICAL
TODDLER ACCIDENT
Seventeen-month-old
Stephanie falls backward and strikes the back of her head on
the kitchen floor with a loud "thunk!" She cries immediately,
and tries to get up within a few seconds.
After crying
vigorously for a few minutes, Stephanie begins sucking her thumb
and wants to to go to sleep.
If Stephanie
did not lose consciousness right after the fall, has good color,
and is breathing normally, she probably has not suffered any
serious injury. It would be all right to allow her a short nap.
Drowsiness is quite common after a painful injury, especially
a bump on the head.
The child's behavior
immediately after a head injury is important. If she cries immediately
(and appropriately), and acts and looks well, check for cuts
and lumps on the head and then let her resume her activities.
Let her sleep
if she wants to, as long as she looks like her usual self. Make
sure to awaken her for a quick check after 20 or 30 minutes.
If she is easily awakened, moves her arms and legs well, responds
to you normally and can walk and play, the injury is probably
very minor and there is no real "head injury."
A REAL WHACK
ON THE HEAD
Justin's coach
insists his Little League players wear protective helmets during
the game. It was after the game that Justin walked into a full
swing of the bat by one of his teammates.
The bat struck
Justin on his right forehead, knocking him down. He appeared
to be stunned and lay motionless on the ground for about a half-minute.
A large knot appeared almost instantly.
Justin began
crying quietly, and on the drive home, he vomited and appeared
dazed. He was able to walk slowly into his house with some support.
He was very quiet, but he know where he was and what had happened.
He vomited again.
Justin's injury
is certainly more severe than Stephanie's. He shows signs of
having sustained a mild "concussion" and needs to be
checked right away in his doctor's office or in the emergency
room.
"CONCUSSION"
A "concussion"
injury is, simply speaking, a shaking up of the brain caused
by a fall or a blow to the head. It may or may not be associated
with a loss of consciousness, vomiting, or an accompanying skull
fracture.
Justin is not
going to feel right for several days. It takes from one day to
a week for the brain to get back to normal after a concussion.
A severe concussion many cause unconsciousness lasting for days.
If a skull fracture
or bleeding within the brain is suspected, one of the newer imaging
techniques such as a CT scan or an MRI study is used, rather
than a plain X-ray.
These are sophisticated
(and expensive) studies that can show depressed skull fractures
and provide details of the soft tissue structures (including
the brain and blood vessels) near the site of the injury, as
well as other areas of the central nervous system.
Skull X-rays,
CT scans, or MRI studies are certainly not indicated in most
everyday head injuries.
"GOOSE
EGGS"
What should you
do right away when a child has a head injury? If there is an
expanding "goose egg" on the scalp, shape crushed ice
into a lemon-sized ball in a washcloth and apply it directly
to the lump. Use moderate pressure. Apply the ice for five to
ten minutes (or as long as the child will let you), wait a few
minutes, then repeat.
Kids usually
hate this, but it prevents the lump (called a "hematoma")
from growing.
By the way, a
goose egg on the scalp does not necessarily indicate a deeper
injury below the surface. Even a minor blow can cause a rather
large lump.
Parents shouldn't
be surprised if a child who has a goose egg on the forehead wakes
up the next day with a "shiner," even though the eye
itself was not injured initially.
A BANG ON
THE HEAD AND A CUT
Four-year-old
Scott tripped over a toy truck and strict his head on a window
sill. Blood began pouring down his face. Scott screamed and headed
for Mama.
She brought him
to the bathroom and pressed a pad made of a folded cold, wet
towel directly over the bleeding area to stem the flow of blood.
Scott had a small laceration on the scalp, and, due to a supergood
supply of blood vessels, scalps can really bleed!
Scott's laceration
from a glancing blow inflicted by the sharp edge of the window
sill is a very common injury. After stopping the initial flow
of blood and determining Scott's mental status (awake? alert?
groggy?), a closer examination of his wound should reveal whether
or not stitches are necessary. (More on stitches below.)
SEVERE HEAD
INJURIES
Immediate evaluation
at a hospital emergency room is necessary following a head injury
if the child is unconscious or non-responsive. Call 911 immediately.
If the child
is not breathing, make sure there is nothing blocking the airway,
and then begin mouth-to-mouth respiration.
To control major
bleeding, make a large pad with any clean cloth (handkerchief,
towel, even a reasonably clean T-shirt). Hold the pad over the
wound and press firmly.
If there is an
object in the wound, such as a rock or piece of metal, do not
attempt to remove it unless it hinders moving the child.
Any obvious deformity
of the skull should NOT be corrected by the person giving first
aid.
With a severe
head injury, especially one resulting from a fall from a height,
it's possible that the neck is also injured. Be extremely careful
with head movements.
Keep the victim
comfortable and warm, stop any major bleeding, insure an adequate
airway, and wait for the paramedics.
STOP THE BLEEDING
I have already
described the method of stopping bleeding in the scalp. That
"direct pressure" method certainly applies to any part
of the body.
Application of
a tourniquet should NEVER, NEVER be used for control of bleeding
as a first aid measure, except perhaps in a severe wound such
as an accidental amputation of a limb. Direct pressure almost
always does the job.
WHAT ABOUT
STITCHES?
When does a wound
need stitches? This question comes up over and over in my practice.
If it's a shallow wound, involving just the outer layers of the
skin, and the edges either fall together or can be easily closed
with tape or a Band Aid, it probably doesn't need stitches. Deeper
cuts, where the underlying tissue can be seen between the wound
edges, usually require stitches for closure.
Lacerations on
the face (especially eyelids and around the lips) are special.
Even shallow wounds may heal better and with less scarring if
they are sutured.
If your child
is cut and you are not sure if stitches are needed, your doctor
or the triage nurse in the emergency room should evaluate the
wound.
Sometimes deep
scratches or shallow lacerations look worse cosmetically AFTER
suturing them than they would have if left to heal spontaneously.
this is due to the stitch marks left on the skin after healing.
There are special tapes available for closing wounds that are
sometimes used to repair cuts in cases where sutures might be
hard to place or where stitch marks would be unsightly.
Clean lacerations
of the finger pads (such as those caused by a clean, sharp knife)
will usually heal without stitches. Gently squeeze the cut end
of the finger to stop the bleeding (this may take 15 or 20 minutes),
then cover with a simple dressing such as a Band Aid.
Wounds will heal
faster and with less scarring if they are kept dry during the
healing process.
It's always frightening
to see your child injured. I hope this article helps you to know
what to check. Do not hesitate to call your pediatrician or the
local hospital emergency room nurse for advice if you have any
concerns - that's what we're here for.
Philip H. Chamberlain,
M.D., is a pediatrician with a private practice in Orinda. He
is the past president of the medical staff at Children's Hospital,
oakland and is a diplomate of the American Board of Pediatrics
and a fellow of the American Academy of Pediatrics.
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Decreasing
level of consciousness, from awake to drowsy, to lethargic, and
then to unconsciousness. An improving head injury may go through
this sequence in reverse. Frequently, a patient may show extreme
restlessness prior to deterioration of consciousness.