My child fell and hit her head. 
There’s a big bump on her forehead. 
What should I do? Do I need to go to the emergency room?

Head injuries are very common, and in considering how serious one might be, there are several factors that we need to examine.  Some of the worst looking bumps, bruises, and goose eggs pose absolutely no danger to your child’s brain at all because they are simply signs that the skin took the brunt of the injury. This is especially true on the thick-boned forehead.  In fact, if you are going to hit your head, the forehead is the best place to do it. Have you ever seen a martial artist break brick with the side or back of his head? So if I see an alert child with a giant goose egg on the forehead after running into a doorknob, I’m usually pretty darn sure he will be OK. I always joke with patients that God made kids short, light, and slow for a reason. Now the temples, on the other hand, are a bad place to hit your head. Swelling there always concerns me for the possibility of a skull fracture. I once saw a kindergarten aged child who ran into another child on the playground and had a skull fracture in the temple.

Below are some important points to consider when deciding whether you should call 911, call our office, or just head to the ER.

1. Any fall or head injury in a newborn should prompt you to call 911.  This age group is at much higher risk for bleeds in the brain than older infants and children. This is due to a soft skull and blood vessels in the brain that bleed more easily.


2. The mechanism of injury is important.  A fall off a couch (a newborn being the exception) or bumping into a doorknob or drywall is unlikely to lead to a serious brain injury, no matter how bad the swelling and bruise.   A fall from a balcony, a head injury in a car accident, a baseball pitch or line drive to the head, a fall off a bike, or an assault should be seen immediately.


3. Any infant or child who loses consciousness from a head injury, even for a moment, should be seen immediately.  When I say lose consciousness I don’t necessarily mean looks dazed for a moment. I mean out cold. If he remains unconscious for more than a few seconds, call 911 and do not try to move him as there could be an associated neck injury.


4. If there is a progressive decrease in alertness, call 911.  A way to distinguish this from just normal sleepiness at a late hour is to see if you can awaken your child and get him to respond appropriately to you.  This can be done successfully with even the sleepiest of children, but a child with a bleed inside the skull may not respond appropriately (i.e. wake up and be coherent).  It’s always a good idea to awaken her every 2 to 3 hours after a head injury to make sure she is responsive. Don’t be afraid to be annoying (or cause a little pain) in your attempt to awaken her. One of my favorite tricks is to rub the sternum (breast bone) back and forth with my knuckles. Ice to the face is another good one. If a semi-painful or annoying maneuver doesn’t awaken her and make her say “Dad, what the heck are you doing???”, call 911.

5.
If none of the above occurs but your child is vomiting please call us immediately. If we are closed take her to the emergency room as soon as possible. Vomiting 15 minutes or longer after the injury is more concerning than vomiting within a couple minutes of the injury. Young kids will often cry very hard right after a trivial injury and make themselves cough and vomit (for example after bumping their heads into a door or falling off the couch). In this situation you need not worry.

Head injuries and breath holding spells
One other interesting situation you might encounter is a breath holding spell. Some children after an upsetting event (for example brother threw a block at his head) will look like they are shocked, hold their breath, change colors, and pass out. They may even stiffen and jerk like they are having a seizure. They will come to soon enough, fear not.

Bleeding disorders
If your child has a bleeding disorder like hemophilia or ITP, please call us or take him to the ER after any head injury just to get checked out.

CT Scans
Keep in mind, that, although we recommend seeking medical attention in the above situations, that does not necessarily mean we are recommending a CT scan. In fact, most head injuries do not require a CT scan and can be properly evaluated through history, physical examination, and sometimes observation. The purpose of the head CT is to look for a bleed inside the skull that will require neurosurgery, not to diagnose a concussion. Fortunately research has given us a better understanding of which signs and symptoms suggest such a bleed, which should allow us to decrease the amount of radiation children receive from unnecessary CT scans.

Concussions
Concussions can occur with relatively minor head injuries or more severe head injuries. Nobody can really predict how bad a concussion is or how long someone will be out of activities. They are essentially a brain injury, but not the type that requires any surgery or intensive care monitoring. Kids have symptoms such as headache, light headedness, dizziness, nausea, forgetfulness, and poor concentration. If your child has had a concussion, we will recommend a period of absolute rest from exercise, media activities (TV, smartphone, video games, etc), school work, and even going out and about. Return to normal activity is a gradual process of making sure your child has no symptoms or signs each step of the way. Some of these signs may be very subtle and picked up on tests like ImPACT® (most parents of high school athletes are probably familiar with this test). While it may be frustrating to the child or parent if we seem very deliberate in allowing return to normal activity (especially sports), it is because setbacks can often cause much more severe and prolonged symptoms. We want your child to be well for the long haul, if not the big game next week.

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