Pediatric Primary Care (113 page)

b.  Dizziness.  

c.  Impaired concentration, thinking, and memory.  

d.  Blurred vision.  

e.  Distractibility.  

f.  Noise sensitive.  

g.  Depression.  

h.  Anxiety.

3.  Severe head injury symptoms:

a.  Impaired hearing, smell, taste, or vision.

b.  Irritability, personality changes, unusual behavior.

c.  Severe headache.

E.  Physical findings.

1.  Minor head injuries.

a.  Unsteadiness.

b.  Fatigue.

c.  Irritability.

2.  Severe head injuries.

a.  Changes in or unequal pupils.

b.  Convulsions.

c.  Fracture in skull or face, bruising of face, swelling at site of injury.

d.  Inability to move one or more limbs.

e.  Loss of consciousness, confusion, drowsiness.

f.  Restlessness, clumsiness, lack of coordination.

g.  Stiff neck or vomiting.

F.  Diagnostic tests.

1.  Important to obtain history of exact details of injury.

2.  Glasgow Coma Scale.

3.  Head CT to identify significant contusion, hemorrhage, and swelling.

4.  Skull and cervical plain films to evaluate skull or neck trauma.

5.  Angiogram to evaluate blood vessels in cases of bleeding.

6.  Certain cases may require CBC, comprehensive metabolic panel (CMP), blood alcohol level, drug screen, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen.

G.  Differential diagnosis.

H.  Treatment.

1.  Mild head injury–treated at home as long as someone available to monitor.

2.  Acetaminophen for pain.  No aspirin or ibuprofen due to increased risk of bleeding.

3.  
Do not:

a.  Wash head wound that is deep or profusely bleeding.

b.  Remove any object sticking out of wound.

c.  Move the person unless absolutely necessary.

d.  Shake the person to arouse.

e.  Remove helmet if you suspect a serious head injury.

f.  Pick up a fallen child with any sign of head injury.

4.  Apply ice to reduce swelling.

5.  Roll on side if vomiting.

6.  Cover bleeding area with clean cloth, only press firmly if no concern for skull fracture.

7.  Always treat as if spinal injury if patient unconscious, keep head midline and immobile.

8.  Maintain airway and vital signs, CPR if needed.

9.  Admit to hospital for severe injury, monitor for progression of symptoms or concern for increased ICP.

I.  Complications.

1.  Increased ICP.

2.  Surgery to remove objects, control hemorrhage, or decompress brain.

3.  Seizures.

4.  Resulting focal deficits.

a.  Weakness, aphasia, personality and intellectual changes, depression, anxiety, aggression, loss or change in: sensations, hearing, vision, taste, smell, speech, or language.

5.  Paralysis.

6.  Chronic headaches.

J.  Follow up.

1.  Seek care immediately for:

a.  Vomiting more than once.

b.  Confusion.

c.  Drowsiness, unable to awaken.

d.  Weakness or inability to walk.

e.  Severe headache.

f.  Severe head trauma or fall from more than height of the person.

g.  LOC for > 1 minute.

h.  Stops breathing.

i.  Severe head or facial bleeding.

2.  Follow up in 1 week after injury and every few weeks to monitor for and manage any sequelae.

K.  Education.

1.  Wear helmets for biking, skating, and other similar sports.

2.  Wear proper sports equipment, and make sure in good condition.

3.  Wear seat belts, use age-appropriate car seats.

4.  Prevent falls by childproofing home–stairs, bathtubs, rugs, furniture.

5.  Be visible and obey traffic laws when biking.

6.  Safe areas to play.

7.  Know signs and symptoms of head injury/concussion and know when to seek medical care.

IV.  CONCUSSION

A.  Alteration in mental status after a blow to the head, consciousness may or may not occur.

B.  Etiology.

1.  Type of traumatic brain injury caused from: bump, blow, or jolt to the head.

2.  Blow to body can cause head and brain to move rapidly back and forth, resulting in head injury.

3.  Results from falls, MVA, and players that collide with each other, ground, or obstacles.

C.  Occurrence.

1.  135,000 sports- and recreation-related TBIs come to emergency departments (EDs) each year (includes concussions in children age 5-18 years).

2.  Athletes who have had a concussion are at increased risk for another.

3.  Children and teens are more likely to get a concussion and take longer to recover than adults.

4.  More than 2 million concussions happen per year, 85% never diagnosed.

5.  50% of football players may experience one concussion per year.

D.  Clinical manifestations.

1.  Hallmark signs–confusion and amnesia that may occur immediately or several minutes after injury occurs.

2.  Early (minutes and hours) symptoms experienced:

a.  Headache.

b.  Dizziness or vertigo.

c.  Lack of awareness of surroundings.

d.  Nausea or vomiting.

3.  Late (days to weeks) symptoms experienced:

a.  Persistent low-grade headache.

b.  Light-headedness.

c.  Poor attention and concentration.

d.  Memory dysfunction.

e.  Easy fatigability.

f.  Irritability and low frustration tolerance.

g.  Intolerance to bright light or loud noises.

h.  Anxiety or depressed mood.

E.  Physical findings.

1.  Vacant stare.

2.  Delayed verbal and motor responses.