A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.
Head injury is classified as either closed or open (penetrating).
- A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull.
- An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.
Head injuries include:
- Concussion, the most common type of traumatic brain injury, in which the brain is shaken
- Contusion, which is a bruise on the brain
- Scalp wounds
- Skull fractures
See also:
Considerations
Every year, millions of people have a head injury. Most of these injuries are minor because the skull provides the brain with considerable protection. The symptoms of minor head injuries usually go away on their own. More than half a million head injuries a year, however, are severe enough to require hospitalization.
Learning to recognize a serious head injury and give basic first aid can make the difference in saving someone's life.
Causes
Common causes of head injury include traffic accidents, falls, physical assault, and accidents at home, work, outdoors, or while playing sports.
Symptoms
The symptoms of a head injury can occur immediately or develop slowly over several hours or days. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. The head may look fine, but complications could result from bleeding or swelling inside the skull.
In any serious head trauma, always assume the spinal cord is also injured.
Some head injuries result in prolonged or nonreversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. More serious head injuries may cause the following symptoms:
- Changes in, or unequal size of pupils
- Chronic or severe headaches
- Coma
- Fluid draining from nose, mouth, or ears (may be clear or bloody)
- Fracture in the skull or face, bruising of the face, swelling at the site of the injury, or scalp wound
- Irritability (especially in children)
- Loss of consciousness, confusion, or drowsiness
- Loss of or change in sensation, hearing, vision, taste, or smell
- Low breathing rate or drop in blood pressure
- Memory loss
- Mood, personality, or behavioral changes
- Paralysis
- Restlessness, clumsiness, or lack of coordination
- Seizures
- Speech and language problems
- Slurred speech or blurred vision
- Stiff neck or vomiting
- Symptoms improve, and then suddenly get worse (change in consciousness)
First Aid
Get medical help immediately if the person:
- Becomes unusually drowsy
- Behaves abnormally
- Develops a severe headache or stiff neck
- Loses consciousness, even briefly
- Vomits more than once
For a moderate to severe head injury, take the following steps:
- Call 911.
- Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing andCPR.
- If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head, keeping the head in line with the spine and preventing movement. Wait for medical help.
- Stop any bleeding by firmly pressing a clean cloth on the wound. If the injury is serious, be careful not to move the person's head. If blood soaks through the cloth, do NOT remove it. Place another cloth over the first one.
- If you suspect a skull fracture, do NOT apply direct pressure to the bleeding site, and do NOT remove any debris from the wound. Cover the wound with sterile gauze dressing.
- If the person is vomiting, roll the head, neck, and body as one unit to prevent choking. This still protects the spine, which you must always assume is injured in the case of a head injury. (Children often vomit once after a head injury. This may not be a problem, but call a doctor for further guidance.)
- Apply ice packs to swollen areas.
For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours. The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness, such as "What is your name?"
If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.
Over-the-counter pain medicine, such as acetaminophen, may be used for a mild headache. Do NOT take aspirin, ibuprofen, or other anti-inflammatory medications because they can increase the risk of bleeding.
DO NOT
- Do NOT wash a head wound that is deep or bleeding a lot.
- Do NOT remove any object sticking out of a wound.
- Do NOT move the person unless absolutely necessary.
- Do NOT shake the person if he or she seems dazed.
- Do NOT remove a helmet if you suspect a serious head injury.
- Do NOT pick up a fallen child with any sign of head injury.
- Do NOT drink alcohol within 48 hours of a serious head injury.
When to Contact a Medical Professional
Call 911 if:
- There is severe head or facial bleeding
- The person is confused, drowsy, lethargic, or unconscious
- The person stops breathing
- You suspect a serious head or neck injury, or the person develops any signs or symptoms of a serious head injury
Prevention
- Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats.
- Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course.
- Be visible. Do NOT ride a bicycle at night unless you wear bright, reflective clothing and have proper headlamps and flashers.
- Use age-appropriate car seats or boosters for babies and young children.
- Make sure that children have a safe area in which to play.
- Supervise children of any age.
- Do NOT drink and drive, and do NOT allow yourself to be driven by someone whom you know or suspect has been drinking alcohol or is otherwise impaired.
Alternative Names
Brain injury; Head trauma; Concussion
References
Heegaard WG, Biros MH. Head. In: Marx J. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, Mo: Mosby; 2009:chap. 38.
Atabaki SM. Pediatric head injury. Pediatr Rev. 2007;28(6):215-224.
Update Date: 1/12/2011
Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
Subarachnoid hemorrhage
Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space.
Causes
Subarachnoid hemorrhage can be caused by:
- Bleeding from an arteriovenous malformation (AVM)
- Bleeding disorder
- Bleeding from a cerebral aneurysm
- Head injury
- Unknown cause (idiopathic)
- Use of blood thinners
Injury-related subarachnoid hemorrhage is often seen in the elderly who have fallen and hit their head. Among the young, the most common injury leading to subarachnoid hemorrhage is motor vehicle crashes.
Subarachnoid hemorrhage caused by a cerebral aneurysm that breaks open (ruptures) occurs in about 40 - 50 out of 100,000 people over age 30. Subarachnoid hemorrhage due to rupture of a cerebral aneurysm is most common in persons ages 20 to 60. It is slightly more common in women than men.
Risks include:
- Aneurysm in other blood vessels
- Fibromuscular dysplasia (FMD) and other connective tissue disorders
- High blood pressure
- History of polycystic kidney disease
- Smoking
A strong family history of aneurysms may also increase your risk.
Symptoms
The main symptom is a severe headache that starts suddenly and is often worse near the back of the head. Patients often describe it as the "worst headache ever" and unlike any other type of headache pain. The headache may start after a popping or snapping feeling in the head.
Other symptoms:
- Decreased consciousness and alertness
- Eye discomfort in bright light (photophobia)
- Mood and personality changes, including confusion and irritability
- Muscle aches (especially neck pain and shoulder pain)
- Nausea and vomiting
- Numbness in part of the body
- Seizure
- Stiff neck
- Vision problems, including double vision, blind spots, or temporary vision loss in one eye
Other symptoms that may occur with this disease:
- Eyelid drooping
- Pupil size difference
- Sudden stiffening of back and neck, with arching of the back (opisthotonos; not very common)
Exams and Tests
Signs include:
- A physical exam may show a stiff neck
- A brain and nervous system exam may show signs of decreased nerve and brain function (focalneurologic deficit)
- An eye exam may show decreased eye movements -- a sign of damage to the cranial nerves (in milder cases, no problems may be seen on an eye exam)
If your doctor thinks you may have a subarachnoid hemorrhage, a head CT scan (without contrast dye) should be done right away. In 5 - 10% of cases, the scan may be normal, especially if there has only been a small bleed. If the CT scan is normal, a lumbar puncture (spinal tap) must be performed.
Other tests that may be done include:
- Cerebral angiography of blood vessels of the brain
- CT scan angiography (using contrast dye)
- Transcranial Doppler ultrasound -- to look at blood flow in the arteries of the brain
- Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) (occasionally)
Treatment
The goals of treatment are to:
- Save your life
- Repair the cause of bleeding
- Relieve symptoms
- Prevent complications such as permanent brain damage (stroke)
Surgery may be done to:
- Remove large collections of blood or relieve pressure on the brain if the hemorrhage is due to an injury
- Repair the aneurysm if the hemorrhage is due to an aneurysm rupture
If the patient is critically ill, surgery may have to wait until the person is more stable.
Surgery may involve:
- Craniotomy (cutting a hole in the skull) and aneurysm clipping -- to close the aneurysm
- Endovascular coiling -- placing coils in the aneurysm to reduce the risk of further bleeding
If no aneurysm is found, the person should be closely watched by a health care team and may need more imaging tests.
Treatment for coma or decreased alertness includes:
- Draining tube placed in the brain to relieve pressure
- Life support
- Methods to protect the airway
- Special positioning
A person who is is conscious may need to be on strict bed rest. The person will be told to avoid activities that can increase pressure inside the head, including:
- Bending over
- Straining
- Suddenly changing position
Treatment may also include:
- Medicines given through an IV line to control blood pressure
- Nimodipine to prevent artery spams
- Painkillers and anti-anxiety medications to relieve headache and reduce pressure in the skull
- Phenytoin or other medications to prevent or treat seizures
- Stool softeners or laxatives to prevent straining during bowel movements
Outlook (Prognosis)
How well a patient with subarachnoid hemorrhage does depends on a number of different factors, including:
- Location and amount of bleeding
- Complications
Older age and more severe symptoms can lead to a poorer outcome.
People can recover completely after treatment, but some people may die even with aggressive treatment.
Possible Complications
Repeated bleeding is the most serious complication. If a cerebral aneurysm bleeds for a second time, the outlook is much worse.
Changes in consciousness and alertness due to a subarachnoid hemorrhage may become worse and lead to coma or death.
Other complications include:
- Complications of surgery
- Medication side effects
- Seizures
- Stroke
When to Contact a Medical Professional
Go to the emergency room or call the local emergency number (such as 911) you have symptoms of a subarachnoid hemorrhage.
Prevention
Identifying and successfully treating an aneurysm can prevent subarachnoid hemorrhage.
Alternative Names
Hemorrhage - subarachnoid
References
Selman WR, Hsu D, Tarr RW, Ratcheson RA. Vascular diseases of the nervous system: intracranial aneurysms and subarachnoid hemorrhage. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J, eds.Neurology in Clinical Practice. 5th ed. Philadelphia, Pa: Butterworth-Heinemann Elsevier; 2008:chap 55C.
Zivin J. Hemorrhagic cerebrovascular disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 432.
Reinhardt MR. Subarachnoid hemorrhoid. J Emerg Nurs. 2010;36(4):327-329.
Rabinstein AA, Lanzino G, Wijdicks EF. Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid hemorrhage. Lancet Neurol. 2010;9(4):504-519.
Update Date: 2/5/2011
Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by Joseph V. Campellone, MD, Division of Neurology, Cooper University Hospital, Camden, NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
Subdural hematoma
A subdural hematoma is a collection of blood on the surface of the brain.
Causes
Subdural hematomas are usually the result of a serious head injury. When one occurs in this way, it is called an "acute" subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.
Subdural hematomas can also occur after a very minor head injury, especially in the elderly. These may go unnoticed for many days to weeks, and are called "chronic" subdural hematomas. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In the elderly, the veins are often already stretched because of brain atrophy (shrinkage) and are more easily injured.
Some subdural hematomas occur without cause (spontaneously).
The following increase your risk for a subdural hematoma:
- Anticoagulant medication (blood thinners, including aspirin)
- Long-term abuse of alcohol
- Recurrent falls
- Repeated head injury
- Very young or very old age
Symptoms
- Confused speech
- Difficulty with balance or walking
- Headache
- Lethargy or confusion
- Loss of consciousness
- Nausea and vomiting
- Numbness
- Seizures
- Slurred speech
- Visual disturbances
- Weakness
In infants:
- Bulging fontanelles (the "soft spots" of the baby's skull)
- Feeding difficulties
- Focal seizures
- Generalized tonic-clonic seizure
- High-pitched cry
- Increased head circumference
- Increased sleepiness or lethargy
- Irritability
- Persistent vomiting
- Separated sutures (the areas where growing skull bones join)
Exams and Tests
Always get medical help after a head injury. Older persons should receive medical care if they shows signs of memory problems or mental decline. An exam should include a complete neurologic exam.
Your doctor may order a brain imaging study if you have any of the following symptoms:
- Confused speech
- Difficulty with balance or walking
- Headache
- Inability to speak
- Lethargy or confusion
- Loss of consciousness
- Nausea and vomiting
- Numbness
- Recent congitive decline in an elderly person, even without a history of brain injury
- Seizures
- Slurred speech
- Visual disturbance
- Weakness
Treatment
A subdural hematoma is an emergency condition.
Emergency surgery may be needed to reduce pressure within the brain. This may involve drilling a small hole in the skull, which allows blood to drain and relieves pressure on the brain. Large hematomas or solid blood clots may need to be removed through a procedure called a craniotomy, which creates a larger opening in the skull.
Medicines used to treat a subdural hematoma depend on the type of subdural hematoma, the severity of symptoms, and how much brain damage has occurred. Diuretics and corticosteroids may be used to reduce swelling. Anticonvulsion medications, such as phenytoin, may be used to control or prevent seizures.
Outlook (Prognosis)
The outlook following a subdural hematoma varies widely depending on the type and location of head injury, the size of the blood collection, and how quickly treatment is obtained.
Acute subdural hematomas present the greatest challenge, with high rates of death and injury. Subacute and chronic subdural hematomas have better outcomes in most cases, with symptoms often going away after the blood collection is drained. A period of rehabilitation is sometimes needed to assist the person back to his or her usual level of functioning.
There is a high frequency of seizures following a subdural hematoma, even after drainage, but these are usually well controlled with medication. Seizures may occur at the time the hematoma forms, or up to months or years afterward.
Possible Complications
- Brain herniation (pressure on the brain severe enough to cause coma and death)
- Persistent symptoms such as memory loss, dizziness, headache, anxiety, and difficulty concentrating
- Seizures
- Temporary or permanent weakness, numbness, difficulty speaking
When to Contact a Medical Professional
A subdural hematoma requires emergency medical attention. Call 911 or your local emergency number, or go immediately to an emergency room after a head injury.
Spinal injuries often occur with head injuries, so try to keep the person's neck still if you must move him or her before help arrives.
Prevention
Always use safety equipment at work and play to reduce your risk of a head injury. For example, use hard hats, bicycle or motorcycle helmets, and seat belts. Older individuals should be particularly careful to avoid falls.
Alternative Names
Subdural hemorrhage
References
Biros MH, Heegaard WG. Head injury. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 38.
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Update Date: 6/28/2010
Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
