Head Injuries

by Steve Sainsbury, MD

Head trauma can be very scary. We tend to remain calm for the more common injuries, such as broken bones or lacerations. After all, they do not pose a risk to our most precious organ, the brain. But even a minor blow to the head often creates a sense of panic in everyone connected to the event.

Television and movies are partially to blame for our heightened worries over head injuries. Who hasn't seen a hapless victim fall backwards and strike their head on a fireplace, only to be dead within seconds? Or the dazed, nearly unconscious teenager being rushed to the ER, while his friends frantically shake him and yell, "Stay awake! Stay with us until we get to the hospital!"

Which brings me to the myth of the day: "Never let a head-injured victim fall asleep."

Consider this common scenario.

Just before bedtime, Billy, your active two-year old, strikes his forehead on the doorjamb. He cries immediately (screaming might be a more accurate description), but within minutes is consoled and relatively happy. Billy is tired and wants to go to sleep, but you keep him awake using every means necessary. (After all, if he falls asleep, he might never wake up.) As you diligently observe him over the next couple of hours, a goose-egg develops above his eyebrow. By the time you get to the hospital, Billy is cranky at having been kept up several hours past his bedtime, and you are exhausted from your efforts. Furthermore, speaking as an emergency physician, trying to assess the mental status of an over-tired and irritable two-year old can be quite a challenge.

Let the poor kid sleep.

It doesn't matter if a head-injured patient falls asleep. Sleeping is not a problem. What is important is whether or not they can be awakened. If not - if they cannot be stimulated to wake up - then they are not actually sleeping. They are unconscious. Now that's something to worry about.

Think of what happens when you get bonked on the head. Your brain bounces inside the hard, bony skull, sometimes rather violently. You may or may not have a brief loss of consciousness. The fragile brain can get bruised and swollen. This is usually referred to as a concussion. Initially, you may feel sleepy, followed by a few days of a headache, some nausea, and light-headedness.

What can we do for this type of head injury?

Not much. You will need to rest and be careful not to get re-injured until your brain has healed.

What doctors really worry about is bleeding inside the head, between the skull and the brain. A growing collection of blood—called a hematoma—squishes the brain, causing lethargy or unconsciousness. If untreated, an expanding hematoma can result in permanent brain injuries and even death. Surgery can be life saving.

Another common misconception about head injuries is that X-rays are needed to look for a skull fracture.

Are they? Not really.

First of all, while plain X-rays may show if the skull has been fractured, they do not answer the more important question: How's the brain doing? Secondly, there is no real treatment for a skull fracture as long as the brain is okay. Most patients do not even have to stay in the hospital.

In conclusion, treat all head-injured people—young and old—with caution, seeking a medical evaluation for any concern about a concussion or more significant injury. But while you are waiting, don't keep jostling or yelling at them to keep them awake. Relax and let them sleep if they want to. We have wonderfully annoying ways of waking up patients in the ER.

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Mountain Gorilla image on banner by Steve Sainsbury, taken during from one of his stays in Rwanda.