Cook Drops The Ball

This week’s guest columnists are Drs. Jordan Conway and Amir Farizani, Family Practice residents at the University Hospital and Clinics here in Lafayette.

Watching the instant replay, I saw exactly when Jared Cook lost consciousness.  In yesterday’s Saints game against the 49ers, he made a great catch, and hung onto the ball through his fall.  But as he lands he’s hit in the helmet.  His hands go slack, and the ball rolls away. To return to play, Cook will undergo daily neurological evaluations while his brain heals. Then he must stay well under increasingly challenging conditions- during exercise, then drills, then scrimmaging.

Concussion is defined as a brain blow followed by loss of consciousness, headache, nausea, trouble with balance or coordination, memory loss, disorientation, and slowed thinking.  Bright lights and loud sounds can make it worse.  Irritability, depression, anxiety, and mood swings are also part of the picture.  Concussion isn’t brain bleeding or skull fractures.  It doesn’t show up on scans- it’s simply defined by the symptoms.

It’s important to immediately remove an athlete with suspected concussion from the game. Continued blows can worsen the injury; prolonging recovery, worsening pain, and even risking brain swelling and death.  It’s sometimes a while before concussions are obvious to coaches, or the player himself.  Thus with any suspected injury, the player needs a sideline evaluation with one of several tools approved by the league- NFL, NCAA, LHSAA.  Don’t wait until the player is staggering about, slurring his words, and vomiting.

If a player is suspected to have concussion, that’s it for the game.  He needs a more thorough evaluation by his doctor, plenty of rest, pain medicines, and time.  The doctor determines fitness to return to play.  Sometimes the simplest things can bring headaches back- trying to read, math homework, exercise.  It can take weeks for an athlete to be ready to play again.

These rules go for all sports with head injury risks- soccer, cheerleading (lots of throwing and falls off pyramids!), basketball, baseball and softball.  No one’s invented an attractive cheerleading helmet yet, any takers?

Kids are constantly bonking their heads, like when my son was learning to walk.  He would take steps along the couch, holding on for support.  Then he’d toddle away, swaying back and forth.  Once he tipped forward and smacked his forehead on the floor.  My wife squeaked, snatched him up, and looked to me for help.  I froze, mouth gaping. Oh, right, I’m a doctor!  Then I remembered my time in the Pediatric Emergency Department.

In the ER we have guidelines about which head injuries are fine, and which need CT scans for brain bleeding.  There’s separate guidelines for kids under 2 years, and those over 2.  My son was in the under 2 category, so these told me he was okay: he wasn’t knocked out, crying immediately after flopping down. Then later he acted fine. This wasn’t a severe injury mechanism, for his age meaning falls greater than 3 feet; he’s under 2 feet tall.  He had no scalp swelling or other signs of a skull fracture.  Thus I knew he didn’t need an ER visit.  Myth buster- no need to wake him up every hour at night to check on him either.

The criteria are a little different for kids over 2.  Notice I didn’t worry about vomiting in my son.  Toddlers vomit easily, especially when they’re upset.  Vomiting has no correlation with bleeding at that age.  However, over age 2, vomiting is on the worry list.  Other signs are being knocked out and/or having a really bad headache.  Indications of skull fracture are “raccoon sign” (black eyes without a blow to the face) or “battle sign” (bruising behind the ears).  If the child is acting dazed and confused (worse than usual, for your teenagers!), that’s concerning.  Finally, if there’s a severe mechanism of injury, like falls greater than 5 feet, blows by a high-impact object like a thrown baseball, or getting hit by a car while walking or riding a bike without a helmet, get checked!

We don’t CT scan every kid who comes into the ER with a smacked noggin.  CT scans carry a small risk of causing cancer by their radiation dose.  We see all severities of injuries, and with experience and these guidelines can make the scan-or-not call with a cool head. If your kid needs it, he’ll get it.  If not, whew!

He Fell Out Of Bed and Bumped His Head

This week’s guest columnist is Dr. Rachel Kumar, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

Three year-olds sit on barstools.  Three year-olds get the wiggles.  And when you’re in the kitchen making dinner, she does both at the same time.  Then she drops out of sight and you hear a smack and a scream.  You abandon the spaghetti and rush around to find her flat on her back, shrieking at the top of her lungs.

All parents have had this nightmare.  Your child hits his head, screams bloody murder or acts odd in some other way, and you think “do I need to call 911?”  Parents often feel that an immediate assessment is a must.  However, most head injuries don’t require an Emergency Department visit.  Knowing the signs and symptoms of severe head injuries, versus those that can stay home, can save you lots of anxiety, and moolah, on medical bills.

You can simply ask yourself three main questions: What was the mechanism of injury, how was the child immediately after, and how is the child now?  The bad mechanisms- high speed car crashes, getting hit by baseball bats- they’re easy. Get seen!  Likewise, the toddler bonks his head on the coffee table, the car’s rear-ended in a parking lot- stay home!  It’s those in-between patients, like the toddler on the barstool or the baby rolling off the bed, that require some thought.

Here’s the mechanism rules, plain and simple.  If your kid is over two year’s old, it takes a fall from 5 feet or more to generate enough energy for bad head injuries.  Under two years-old: a 3 foot fall.  Use a measuring tape; sometimes we do, to show a parent what three feet looks like.  Is that how high your bed is, we ask?

High energy impacts, like thrown baseballs, swinging bats and golf clubs, also need checking.  Getting hit by a car, whether your kid’s walking or on a bike without a helmet, warrants an ER visit.  Getting hit by a thrown plastic toy- not so much.

Children jump from one couch to another- it’s what they do.  We all, you and me, did it as kids.  Who needs trampoline parks when we all have one at home, whether it’s couches or a room with two beds?  But then the inevitable- young Mary Lou Retton doesn’t stick the landing, stopping the fall with her scalp instead of her feet.

Let’s answer that second question from above: immediately after a head injury, how’s your kid acting?  There’s red flags at this stage that tell us a kid needs medical attention.  Of course, if the child is unconscious, he needs to be seen.  If the child isn’t knocked out, but is acting dazed and talking in a confused manner, that’s worrisome too.  This is the scenario with many football players- they aren’t knocked out, but are staggering around after the blow, can’t remember their plays or what just happened, or  even where they are.

For babies and toddlers, the immediate assessment is more vague.  Of course if after stopping crying, they go back to themselves, walking about and smiling and babbling, you can stay home.  But if they’re acting sleepy, seem more unsteady than usual, or are “just not acting right,” then you should call your doctor, or get seen.

The third question is: how is your child acting now, some time after the injury.  Of course if he goes back to playing and running,it’s cool.  But what if he goes to sleep?  Many kids tend to want to lie down and nap after a traumatic experience and some hard crying, but what’s the line between a normal nap and somnolence from head injury?  If it’s the child’s normal nap time, she takes her usual 30 minute nap and then wakes up, then cool.  But if after a half hour she’s harder-than-usual to wake up, it’s check time.

Other red flags are vomiting after a head injury, or severe headaches.  Children who are squinting and holding their heads hours after a head injury need to get seen.  What about lumps?  Many kids get them, just like characters on Bugs Bunny cartoons, rising from their scalps.  We only worry about lumps on kids under two years-old.  And even then, lumps on foreheads are okay.  Lumps on the sides or back of the head- come on in! 

Put Me Back In Coach!

Dave was the quarterback for my college fraternity’s football team.  Though it was flag football, Dave got knocked down a lot, and several times hit his head on the ground.  For days he would act confused, repeat questions over and over, and finally recover. He graduated to go on to fly Navy jets and finally got a helmet to wear!  Dr. Blake McDonald, a Family Practice resident at the University Hospital and Clinics here in Lafayette, discusses concussions this week: pay attention!

Concussion is an injury caused by a blow to the head.  This injury impairs neurologic function: concussions interfere with coordination, thinking, emotions, and sleep.  They eventually heal, but it takes time.

Concussions aren’t bleeding in the brain or skull fractures- they aren’t detected by CT or MRI scans.  They can be measured by neuropsychological tests, where the patient interacts with a computer program or a paper-and-pencil test.  In other words, concussion is a functional injury, not a structural one.

Concussions are a big problem, bigger than statistics report.  About 144,000 people per year visit ERs for concussions, but one review estimates that there may be up to 3.8 million recreation and sports concussions per year in the U.S.  And that doesn’t include injuries in grade school and middle school athletes.

Football is the riskiest sport for concussions in high-school boys, soccer and basketball for girls.  Rugby, ice hockey, cheerleading, and lacrosse also probably have high concussion rates, but their data are limited since these are often club activities rather than official school sports.

Headache and impaired coordination are the main physical symptoms of concussion. Loss of consciousness is another physical sign, but this only happens in 10% of concussions- you don’t have to be knocked out to have a concussion!

Concussions also affect cognitive function- the ability to think and remember. Kids with concussions have trouble with homework, concentration, and thinking clearly.  Memory is also impaired- a concussed child may not remember what happened for some time before and after the injury.  Some kids have short term memory loss, asking the same question over and over.

Besides causing physical symptoms and thinking deficits, concussion can affect emotional stability.  Concussed kids are often tearful and depressed.  They can be emotionally “labile,” meaning one minute they are acting silly, the next minute moody. Kids with concussions sleep a lot.  This worries parents who have heard not to let head-injured kids sleep.  But sleeping late and napping with a concussion is part of normal healing.

So how can we help concussions heal?  Management involves avoiding activities that slow natural recovery.  This means allowing time for physical, cognitive, and emotional recovery, and not worsening things.  Even the NFL now recognizes that if you send an athlete back out who has impaired coordination, concentration, and thinking, they stand a greater chance of getting more hurt.

Cognitive and physical rest are the mainstays of management.  Cognitive rest means staying home from school.  Upon return, concussed kids may need shorter school days and reduced work.  They may need more time for assignments or tests.  If headaches return, the child may need to be out of school longer.  Videogames and computers can worsen symptoms too.

To be allowed to return to full school work or sports, the child must be symptom-free- no headaches, normal coordination, no trouble thinking or remembering, no more fatigue or depression.  This can be a problem with motivated athletes who hide their symptoms to stay in the game.  Coaches, teachers, and parents need to be vigilant.  If a kid hits her head and then seems impaired, the approach is simple: “when in doubt, sit them out!” Coaches and trainers should be aware of sideline tests for concussion to detect impairment.

When kids do return to school or sports, they need a “graduated” increase in intensity.  This means slowly increasing class work and home work.  In sports, it means slowly increasing physical intensity, then adding complexity (like adding drills and plays), then scrimmaging, then full play.  Worsening symptoms during that time mean “back off!”  

Though there’s been much prevention talk about mouth guards, better headgear, altered sports rules, the best tools to prevent and treat concussions are education and recognition- for athletes, parents, coaches, trainers, teachers, administrators.  And doctors and nurses too!

Baby Fall, Go Boom!

This week’s guest columnist is Dr. Marc Fernandez, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

Bumps, scrapes, and bruises can be found on the scalp of any active child, some so much they look like a scuffed shoe.  Kids explore and lead with their big heads, so it comes with the territory. Usually it’s easy to know when a scalp bump can be cured with a mommy’s kiss.  These are the minor boo-boos from flying soccer balls or cups thrown by grumpy siblings.

It’s also not hard to know when a more traumatic blow requires an Emergency Room visit. It’s an easy decision if your child gets knocked out cold by a baseball bat, or is in a high-impact traffic collision. These obvious ones you bring to the hospital.

What about those in-between injuries:  the short falls on the head from a tree branch, the heavy tackles at football practice, the head-on sprints into an invisible glass door? Even if toddlers cry for a couple of minutes after a smack to the crown, or teens seem a little confused after a soccer ball to the head, they’re usually soon skipping around like nothing happened. However, every parent has heard stories from someone they know, or about a celebrity, who seemed fine after a head injury, didn’t go the hospital, and then didn’t wake up the next morning.  These tales will make any parent rush the kid in with the teensiest knock on the noggin.

Fortunately we now have scientifically valid criteria to evaluate those in-between cases, to decide who needs a brain scan and who doesn’t:

-Does your child complain of a really bad headache, or seem confused?

-Was he knocked out?

-Is she vomiting?

-Did he fall from over 5 feet up, or have another high-impact injury to the head (like a thrown baseball)?

These are the kids who need to get seen, but these criteria apply to kids 2 years-old and up.  What about the smaller fry?

Babies and toddlers fall a lot.  Even before babies can sit up, they will roll.  Off the bed. They tumble out of car seats and strollers.  Then when they first start walking, toddlers look like high-wire artists, weaving about with their arms out for balance, everyone around wondering, will he fall, won’t he?  Then the toddler learns to run, and is not deterred by walls or coffee tables.

Like minor head injuries in older kids from above, it’s usually easy to tell which baby or toddler is okay.  She bonks her head on the coffee table, cries for a minute, and then gets up and runs after the cat.  Baby flops out of the car seat that is on the floor, scrapes his forehead, then goes back to wiggling and cooing, and nurses fine.

So when do we worry?  Our high-risk criteria for older kids we discussed above don’t seem to apply to the littler ones.  How can you tell if baby has a bad headache, or is “confused?”  And many babies vomit daily, whether they hit their head or not.  For these reasons we have separate rules for head injuries involving kids under 2 years-old:

-Does baby have a large bump anywhere on the scalp, except the forehead?  Forehead bumps are allowed, since that is where the skull is hardest, designed for the most common, front-end impacts.

-Did the child lose consciousness for more than 5 seconds?  Many toddlers are temporarily dazed after smacking their heads, so we give them 5 seconds to recover their wits.

-Is the child acting normally, or is he more sluggish or more fussy?

-Did baby fall from more than 3 feet, or have a similarly traumatic blow?

Note that vomiting is not on the list for babies and toddlers.  Some toddlers will vomit when they cry really hard, and many babies spit up randomly.  Vomiting doesn’t correlate with bad head injuries in the littler ones- many toddlers who end up in Pediatric Intensive Care don’t vomit, and many babies who are fine vomit all day anyway.

So when baby falls and goes boom, you will initially freak out and want to rush to the doctor. Then take a breath, think about the above, and use your own noggin to decide!

“He Bumped His Head And Went To Bed…”

Today’s guest columnist is Dr. Jesse Livingston, a family practice resident at the LSU-University Health Center here in Lafayette.  

Kids fall and hit their heads a lot.  Though most children with head injuries are fine, some need evaluation in the Emergency Department.  The parent can have difficult decisions to make, while at the same time dealing with a crying baby: Is the brain okay?  Does my child need a CT scan?  Can he nap?  We have all heard the nursery rhyme about the old man who bumped his head, went to bed, and couldn’t get up in the morning.  What about your two-year old, who despite every effort will “fall and go boom?”

The decision is easy for the worst falls.  If a child loses consciousness, has a seizure, vomits repeatedly, has a severe headache, is lethargic or confused, then she needs to be seen.  The doctor can decide if tests are needed, or if observation is enough.  We need to consider the “mechanism of injury,” meaning how it happened and what force was involved.  A child may seem fine after being struck in the head by a baseball, but such high-speed impacts need evaluation regardless of how well the kid is acting.

Here are more criteria for needing to get seen now: car wrecks where the child is thrown from the car, another passenger in the car dies, or the car rolls over.  If he is hit by a car while walking, or while riding a bike without a helmet, that’s concerning.  Kids under two years old need to be evaluated if they fall from over three feet; kids over two, falls higher than 5 feet.  If an infant or toddler under two gets a “goose egg” swelling anywhere but the forehead, that is worrisome.

However, most kids who hit their heads are okay and can stay home.  Kids who fall from their own, standing height, are usually fine.  Kids who hit their heads but are not knocked out and go back to playing are okay too.  Toddlers who run into walls also don’t generate enough force to hurt themselves badly.

Several times per week in the Emergency Department, we see a baby who rolls off the bed or falls from the stroller.   Mom is understandably freaked out- “I just left the room for a second, she has never rolled over before!”  Most falls occur at home and are usually either from falling off beds or other furniture, tumbling down stairs, or from being dropped. Interventions used only weeks ago to keep baby safe are now obsolete due to the child’s developing abilities.  Add to that the distractions of other children, pets, dinner on the stove, and the rest of the household confusion, and stuff will happen.

Like we said above, after most falls the child doesn’t need an Emergency Department visit.  If baby fell from a height less than three feet, then he is probably fine. Further, if he is acting normally, doesn’t have any “goose egg” swelling on his head (except for the forehead- a goose egg there is okay), doesn’t vomit, and is acting well, he is okay.  If you are unsure, call your doctor.  The doctor can help decide if baby can be observed at home or needs to come in.

Many parents believe they must keep their child awake after a fall to prevent coma. However, this is an “old wive’s tale.”  Naps after a minor fall can be restorative and comforting.  If there is a question about how bad the injury was, we do like an observation period where the child is watched for warning signs (severe headache, vomiting, changes in behavior, confusion).  During normal waking hours this is easy. However, if it is nap or bed time baby can go to sleep, but you should wake him up hourly for a few hours.  If the child is alert after waking (as alert as a child who’s just been awakened can be!), then okay.  If she seems overly groggy or lethargic, call your doctor or come in.

Unlike the old man in the nursery rhyme, most kids who bump their heads and go to bed are perfectly fine- they are not old men!  Someone needs to write a new nursery rhyme for kids who bump their heads.

Baby Fall Go Boom

This week’s guest columnist is Dr. Leslie Birdsong, a family practice resident at the University Health Center here in Lafayette.

You are downstairs doing a million things.  Your kids are upstairs playing, making sounds like herding elephants.  Suddenly you hear a louder crash.  You strain to listen, and have that stab of anxiety: what sound is next?  Laughter and more elephants, or gut-wrenching silence?  You yell up the stairs, “Is everybody ok?” More silence.  Now you are truly frightened and bound up the stairs .

Every parent fears their child having a head injury.  Head injuries make up many hospital visits for kids.  Here are some numbers: In kids less than 14 years, yearly there are over 500,000 Emergency Department visits for head injuries.  37,000 of those kids get admitted to the hospital for observation, or surgery.  So when do you need to bring your child to the hospital?  Here are some rules.

We divide head injuries into two groups: those younger than two years old, and those two and older.  This is because younger children react differently to head injuries. They are more difficult to assess because they can’t tell us what’s wrong. Also, infants may not show many outward signs of injury.

In kids less than two, here are the rules.  1.  Is the child walking, talking, and acting well for their age when we see them in the ED?  2.  Is the child acting like themselves for mom and dad?  You are with your child a whole lot more than the 10 minutes we get. Tell us if your kid is acting “funny.”  3. Are there big lumps on the scalp? Swelling and bruises on the forehead are okay, but swelling on other parts of the skull needs checking.  4.  Did the child lose consciousness?  Any child that gets knocked out should be seen.  5.  Was the injury mechanism severe?  If a child falls over from standing and hits her head- no big deal.  But a fall on the head from greater than three feet could be trouble.  A fender-bender car crash doesn’t require an evaluation, but if the car rolled over the kids need to be checked.  Impacts from baseball bats and golf clubs- bring ‘em in!

For little kids, the common and scary scenario is usually like above- the parent hears boom and then silence.  For older kids it is the call from the school or worse, from the police- your child has had an accident.  Still, most older kids have mild head injuries they easily shake off.  The rules to assess children older than two are a little different than the ones for the babies and toddlers from above.

1.  Is the child awake, alert, and acting normally?  2.  Was the kid knocked out?  3.  Is the child vomiting?  Note that vomiting is NOT on the list for kids under two years- they can vomit just from crying really hard or gagging on mucus.  But if kids over two are vomiting because of a head injury- that worries us.  4.  Does the child have a bad headache?  The littler kids can’t tell us about this but the older kids can, and that counts.  5.  Was the mechanism of injury severe?  This means falls onto the head from greater than 5 feet, a car roll-over, or an impact from a thrown baseball or swung bat.

When a kid meets any of these criteria, they may need a CT scan of the brain.  CT scan helps find bad things like bleeding in the brain or skull fractures.  So why don’t we just scan every kid and be sure?  No, it’s not about the money.  CT scan uses lots of radiation, up to 500 times the radiation of a regular x-ray.  Our physician motto “Do No Harm” comes into play.  The benefit of seeing into the skull needs to outweigh the risk of future cancers.

What is the bottom line here?  If your child falls down and goes boom and has any of the signs we listed, get him seen.  If you are unsure if any of the rules above are positive, call your doctor.  But if you have good answers for all the rules, then all baby needs after falling and going boom is a hug and a kiss on the noggin.

Head Injury Fears, Myths, Precautions

People used to have difficulty naming their fears about when their child hit their head.  Now their fear has a name- Natasha Richardson.  Everyone has heard a story like the famous actress’s.  A person hit their head, looked well at first, then did not wake up in the morning. 

Fortunately, this story of delayed death after head injury is rare in adults.  It is almost unheard of in kids.  When children hit their head the severity is obvious right away.  They come to the ED in two distinct presentations- still unconscious and obviously very sick; or they come in awake, alert, and essentially well.

When can you stay home with your head-injured child then, and avoid a costly and time-consuming ED visit?  Here are the good signs:  your child was not “knocked-out,” his fall was from a distance less than three times his own height, he has no vomiting, and he has no headache.  Some toddlers will get sleepy after crying their hearts out from their sore head.  That is OK- you can let your child sleep, as long as she has not vomited, has drank a little, and acted “with it” since the injury.  After an hour or two, if your child has not awakened, you should wake her up to be sure she walks and acts normally.

What about when baby falls off the bed or out of the car seat and hits her head?   Babies are a little different than older kids- they get skull fractures more easily.  A baby under a year old who hits her head should get checked out if she has any swelling on her scalp.  Of course, she also needs to be seen if she has any loss of consciousness, vomiting, or acts “out of it.”

What if your child was knocked out, is vomiting, or complains of a headache?  Certainly bring him in to get checked out, but don’t panic.  Most of those kids have a concussion but not a bad brain bruise or brain bleeding.  A concussion is when the patient get “his bells rung.”  He feels tired, sick to his stomach, has a headache.  After a normal CT scan, if he can drink without vomiting, he can go home.  The concussion might last for days. 

 The one really important precaution for concussions is that the patient must not take a risk of hitting their head again while they are sick.  The child must not do sports or other risky activity until cleared by their own doctor in a follow-up exam.

Have a head injury story of your own?  Feel free to tell us by clicking on the comments button and writing us.