Head Injury

Overview

Head injury refers to any trauma affecting the scalp, skull, or brain. These injuries range from minor bumps and bruises to life-threatening traumatic brain injuries (TBI). Head injuries are among the most common causes of disability and death, particularly in young adults and elderly populations. Each year, millions of people worldwide sustain head injuries, with causes ranging from falls and motor vehicle accidents to sports injuries and violence.

Head injuries are classified as either closed (no break in the skull) or penetrating (object pierces the skull and enters brain tissue). They can also be categorized by severity: mild (concussion), moderate, or severe. Even seemingly minor head injuries can have serious consequences, as the brain is extremely sensitive to trauma. The effects may be immediate or develop over hours to days after the injury.

Understanding head injuries is crucial because prompt recognition and appropriate treatment can significantly affect outcomes. While many mild head injuries resolve without lasting effects, more severe injuries can lead to permanent disability, personality changes, cognitive impairment, or death. The brain's limited ability to repair itself makes prevention and proper acute management essential.

Symptoms

Head injury symptoms vary widely depending on the severity and location of the trauma. Symptoms may appear immediately or develop gradually over hours or even days following the injury. It's crucial to monitor anyone with a head injury closely, as deterioration can occur rapidly.

Immediate Symptoms

Physical Symptoms

Severity-Based Symptoms

Mild Head Injury (Concussion)

• Brief confusion or disorientation
• Headache and dizziness
• Nausea or vomiting (usually once)
• Ringing in ears
• Fatigue or drowsiness
• Blurred vision
• Memory problems about the event
• Difficulty concentrating
• Mood changes or irritability
• Sleep disturbances

Moderate to Severe Head Injury

• Loss of consciousness for minutes to hours
• Persistent or worsening headache
• Repeated vomiting
• Seizures
• Inability to awaken from sleep
• Pupil dilation (one or both eyes)
• Clear fluids draining from nose or ears
• Weakness or numbness in extremities
• Loss of coordination
• Profound confusion
• Slurred speech
• Agitation or unusual behavior

Causes

Head injuries result from various types of trauma that cause the brain to move within the skull or direct damage to brain tissue. Understanding common causes helps in prevention and determines the type of injury sustained.

Common Causes

• Falls: Leading cause across all ages, especially in children under 4 and adults over 65
  • Falls from beds, ladders, stairs, or in the bath
  • Slips on ice or wet surfaces
  • Falls from heights in construction or other occupations
• Motor vehicle accidents: Major cause of severe head injuries
  • Car, motorcycle, bicycle accidents
  • Pedestrian accidents
  • All-terrain vehicle crashes
• Violence: Assaults, domestic violence, child abuse, gunshot wounds
• Sports injuries: Contact sports, extreme sports, recreational activities
  • Football, hockey, boxing, soccer
  • Skateboarding, skiing, snowboarding
  • Baseball, basketball collisions
• Combat injuries: Blast injuries, shrapnel, direct trauma in military personnel
• Workplace accidents: Construction sites, industrial accidents

Mechanisms of Injury

• Direct impact: Blow to the head causing focal injury
• Acceleration-deceleration: Rapid movement causing brain to hit skull (whiplash)
• Rotational forces: Twisting motion causing diffuse axonal injury
• Penetrating injury: Object piercing skull and brain tissue
• Blast injury: Pressure waves from explosions

Risk Factors

Certain factors increase the likelihood of sustaining a head injury or experiencing more severe outcomes:

Age-Related Factors

• Young children (0-4 years): Developing motor skills, large head-to-body ratio
• Adolescents and young adults (15-24): Risk-taking behaviors, sports participation
• Older adults (65+): Balance problems, medications affecting coordination, osteoporosis

Lifestyle and Behavioral Factors

• Alcohol or drug use impairing judgment and coordination
• Not wearing protective equipment (helmets, seatbelts)
• Participation in high-risk sports or activities
• History of previous head injuries
• Living in high-crime areas
• Military service in combat zones

Medical Conditions

• Bleeding disorders or use of blood thinners
• Epilepsy or seizure disorders
• Balance or gait disorders
• Osteoporosis increasing fracture risk
• Vision problems affecting spatial awareness
• Cognitive impairment or dementia

Environmental Factors

• Hazardous working conditions
• Poor home safety (loose rugs, poor lighting, no handrails)
• Icy or wet conditions
• Inadequate playground safety equipment

Diagnosis

Proper diagnosis of head injury requires immediate assessment to determine severity and guide treatment. Healthcare providers use various tools and tests to evaluate the extent of injury and monitor for complications.

Initial Assessment

• Glasgow Coma Scale (GCS): Standardized assessment of consciousness
  • Eye opening response (1-4 points)
  • Verbal response (1-5 points)
  • Motor response (1-6 points)
  • Total score: 3-15 (13-15 mild, 9-12 moderate, 3-8 severe)
• Neurological examination: Checking reflexes, strength, sensation, coordination
• Vital signs monitoring: Blood pressure, pulse, respiration, temperature
• Pupil examination: Size, equality, and reaction to light

Imaging Studies

• CT scan (Computed Tomography): First-line imaging for acute head injury
  • Detects bleeding, fractures, brain swelling
  • Quick and widely available
  • Decision based on clinical criteria (Canadian CT Head Rule)
• MRI (Magnetic Resonance Imaging): More detailed brain imaging
  • Better for detecting diffuse axonal injury
  • Used for persistent symptoms or follow-up
  • Not typically used in acute setting
• X-rays: Limited use, mainly for suspected skull fractures

Additional Tests

• Neuropsychological testing: Assessing cognitive function after injury
• Blood tests: Checking for complications, drug/alcohol levels
• Intracranial pressure monitoring: In severe cases requiring ICU care
• Electroencephalogram (EEG): If seizures suspected

Treatment Options

Treatment for head injury depends on severity and type of injury. The primary goals are preventing further damage, managing symptoms, and supporting recovery. Treatment ranges from simple observation to complex neurosurgical interventions.

Mild Head Injury (Concussion) Treatment

• Rest: Physical and cognitive rest for 24-48 hours
• Gradual return to activity: Step-wise progression as symptoms improve
• Pain management: Acetaminophen (avoid NSAIDs initially due to bleeding risk)
• Observation: Monitor for worsening symptoms at home
• Avoid: Alcohol, sleeping pills, contact sports until cleared
• Follow-up: Medical reassessment if symptoms persist beyond 2 weeks

Moderate to Severe Head Injury Treatment

• Emergency stabilization:
  • Airway, breathing, circulation management
  • Cervical spine immobilization
  • Prevention of secondary brain injury
• Medical management:
  • Intracranial pressure control
  • Seizure prevention with anticonvulsants
  • Blood pressure and oxygenation optimization
  • Temperature control
  • Sedation and pain management
• Surgical interventions:
  • Craniotomy to remove blood clots
  • Decompressive craniectomy for severe swelling
  • Repair of skull fractures
  • Placement of intracranial pressure monitors

Rehabilitation

• Physical therapy: Restoring strength, balance, coordination
• Occupational therapy: Relearning daily living skills
• Speech therapy: Addressing communication and swallowing issues
• Cognitive rehabilitation: Improving memory, attention, problem-solving
• Psychological support: Managing emotional and behavioral changes
• Vocational rehabilitation: Return to work programs

Long-term Management

• Regular neurological follow-ups
• Management of post-concussion syndrome
• Treatment of complications (hydrocephalus, seizures)
• Support groups and counseling
• Adaptive equipment and home modifications
• Medication management for chronic symptoms

Prevention

Many head injuries are preventable through safety measures and lifestyle modifications. Prevention strategies vary by age group and activity but share common principles of risk reduction and protective equipment use.

General Prevention Strategies

• Vehicle safety:
  • Always wear seatbelts properly
  • Use age-appropriate car seats for children
  • Never drive under influence of alcohol or drugs
  • Avoid distracted driving (texting, phone use)
  • Wear helmets on motorcycles and bicycles
• Sports safety:
  • Wear appropriate protective equipment
  • Follow sport-specific safety rules
  • Ensure proper technique and conditioning
  • Recognize and respect concussion protocols

Home Safety

• Install handrails on stairs and in bathrooms
• Remove tripping hazards (loose rugs, clutter)
• Ensure adequate lighting throughout home
• Use safety gates for young children
• Secure windows to prevent falls
• Place nonslip mats in bathtubs and showers

Age-Specific Prevention

• Children:
  • Supervise playground activities
  • Use proper car seats and booster seats
  • Childproof homes (padding sharp corners)
  • Teach bicycle and sports safety early
• Older adults:
  • Regular vision and hearing checks
  • Review medications affecting balance
  • Exercise programs to improve strength and balance
  • Use assistive devices when needed

When to See a Doctor

Any head injury warrants careful monitoring, but certain signs and symptoms require immediate medical attention:

Call 911 Immediately For:

• Loss of consciousness, even briefly
• Confusion or disorientation that doesn't improve
• Repeated vomiting (more than once)
• Seizure or convulsion
• Severe or worsening headache
• Difficulty staying awake or waking up
• One pupil larger than the other
• Unable to recognize people or places
• Slurred speech
• Weakness or numbness in arms or legs
• Loss of coordination or balance
• Clear fluid or blood from nose or ears
• Unusual behavior or agitation

Seek Medical Care Within 24 Hours If:

• Moderate headache that persists
• Memory problems or confusion
• Dizziness that doesn't resolve
• Nausea without vomiting
• Sensitivity to light or noise
• Mood changes or irritability
• Sleep disturbances
• Any concern about the injury

Special Considerations

• Infants and young children who cannot describe symptoms
• Elderly individuals on blood thinners
• Anyone with a bleeding disorder
• Those with previous brain surgery or multiple concussions

Related Conditions

References

1. Centers for Disease Control and Prevention. Traumatic Brain Injury & Concussion. 2023.
2. Brain Trauma Foundation. Guidelines for the Management of Severe Traumatic Brain Injury. 4th Edition. 2023.
3. American College of Emergency Physicians. Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury. 2023.
4. Maas AIR, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurology. 2022.
5. McCrory P, et al. Consensus statement on concussion in sport. British Journal of Sports Medicine. 2023.
6. National Institute of Neurological Disorders and Stroke. Traumatic Brain Injury Information Page. 2023.