Child head injury is an area of considerable concern for medical professionals around the world. Children engage in too many sports and are thus very vulnerable to head injuries which, as the case may be, maybe minor or more significant. Head injuries range from a slight knock on the head to Traumatic Brain Injury (TBI), with permanent brain damage. For these critical cases of severe brain injury for infants, it can result in non-reversible brain damage as it includes significant bleeding that affects the brain directly. To understand clearly the extent of the injury, we need to look at the numerous symptoms that surface.
Children experience many symptoms by which we could understand if the damage is minor or significant. In this article, we will attempt to examine the different symptoms encountered during serious brain injury, with particular reference to vomiting as one of the symptoms. There are two types of head injuries which are discussed below for us to understand when or why vomiting takes place.
Background of the Study: Types of Head Injuries
The brain is a soft jelly-like tissue that is surrounded by cerebrospinal fluid within the protective cranium. Though this fluid’s protective value is quite limited, yet it acts as a shock absorber. Because the skull serves as a defensive shield for the brain’s fragile tissues, most of these lesions turn out to be minor. When a brain injury is a minor one, the symptoms usually disappear on their own. Furthermore, when children suffer a critical head injury, providing basic first aid and quickly rushing the child to hospital is vital. (WG Heegaard, 2009)
Symptoms of head injury include bruises and cuts, altered consciousness, fatigue and vomiting. One of the most common types of traumatic brain injuries is concussion which involves the brain being severely shaken. A contusion is also a head injury which consists of the bruising of the brain. Many head injuries include skull fractures and scalp wounds. (Atabaki, 2007)
Head Injuries can be classified into two groups
- Head injury closed: when the brain receives a heavy hit but doesn’t get broken, then it’s assumed it’s a closed headache.
- Open head injury: when the skull is severely injured and gets fractured and enters the brain tissues, then it is said to be a free head injury. Such damage can occur when moving at high speeds such as in an accident or by a gunshot to the head.
Symptoms of Severe Brain Damage
Symptoms related to severe brain damage occurs according to the level of damage to the brain. Some people say that when children undergo serious brain injury, vomiting happens, although some claim that vomiting can not be considered a reliable symptom.Other symptoms besides vomiting include chronic headaches, memory loss, seizures, loss of consciousness sometimes leading to coma or paralysis, slurred speech, blurred vision, confused state, drop in blood pressure and other speech, vision and language problems. Among these symptoms, the symptom that will be discussed in detail would be vomiting about severe head injury in children.
Causes of Head Injury in Children
Some of the common causes of head injuries occur due to automobile accidents, skating, pedestrian-car accidents, falling from heights, missiles and other non- accidental trauma such as child abuse. (Gedeit Rainer, 2001) Depending on the degree of brain injury these head injuries can be mild, moderate , or severe. In a mild TBI, the child may experience a loss of consciousness for a very brief period of a few seconds or minutes. There may also be headaches, nausea, temporary memory loss and behavioural and mood changes; however, if the TBI is moderate to severe. In addition to all the symptoms mentioned above, there could also be dilation of pupils, repeated vomiting, numbness of the limbs, loss of coordination, seizures and agitation. Vomiting takes place for many different reasons, and in the case of head injury vomiting occurs due to the intracranial pressure brought about by the impact. (Tintinalli, Judith E. 2010) If the vomiting is profuse, it may alter the electrolyte levels and dehydrate the body. Immediate action should be taken during recurrent vomiting as it is an indicator of severe head injury. (Tintinalli, Judith E. 2010)
(Fiona Brown et al., 2000) conducted a study involving 463 children who had a head injury. The study found that skull fracture did not increase when there was post-traumatic vomiting (PTV) In trying to determine the role of vomiting after a head injury, an investigation of other related factors was carried out such as the family history of migraine and vomiting, site of impact, the presence of haematoma of the scalp etc. and an analysis was carried out making use of the X2 and Fisher’s exact tests. (Fiona Brown et al., 2000) Comparing the vomiters to the non-vomiters, the study found that around 15.8 per cent of the 463 had vomiting after the injury. The associated factors that were identified in connection with vomiting were a history of motion sickness and vomiting. The study concluded that “vomiting alone has no role to play in making decisions about further investigation of the skull or brain.’ (Fiona Brown et al., 2000)
However, in another study conducted by (Nee PA., et al., 1999) involving 2581 children, the incidence of PTV was quite similar to Brown and colleagues research. Still, the rate of skull fracture in children showed 33%. From all the data collected, the study results showed that there was an association between a vomiting episode in children after an injury to the head and the risk of fracture. (Nee PA., et al., 1999)
In another study conducted by (Dunning et al., 2004) in the Children’s Head Injury for Algorithms for the identification of Clinical Events Study (CHALICE) about the current NICE (National Institute of Clinical Excellence) Guidelines and the guidelines of the Royal College of Surgeons (RCS) which was already in use, results showed that the NICE guidelines had much better outcomes than the RCS guidelines that involved CT scans for children with head injuries. To make an investigation of the impact each of the instructions had on patient care, about 11,000 children with head injuries were included in a comprehensive study. (Dunning et al., 2004)
According to the RCS Guidelines, approximately 171 CT scans (1.6%) were required, but according to the NICE Guidelines about 987 CT scans (8.7%) were needed. One of the criteria for marking high-risk patients under 12 years was vomiting, and according to NICE Guidelines, only 714 patients (6.5%) were at high risk. However, the CT scan rate would vary between 6% to 8% depending upon how the clinicians apply the vomiting recommendation. (Dunning et al., 2004)
According to the NICE guidelines, the same is applied for children and adults as well, though excessive vomiting is found in children. The study found that making use of the vomiting criteria for interpretation, while 6.3 % was the mean CT rate, the upper limit of requests for CT scans would rise to about 11% in all emergency departments. The study concluded that requested CT scans would be performed on children with head injury based on the presence of vomiting. (Dunning et al., 2004) However, (Brenner D. et al., 2001)
thinks that unless there is great concern about a severe brain injury, where a CT scan should be avoided since it is not good to expose the child to radiation. Therefore, a thorough evaluation of the injured child is of utmost importance besides proper monitoring of the symptoms. When vomiting is recurrent, the head injury is taken to be dangerous.
According to (Schutzman SA et al., 2001) a CT scan could be recommended when there are signs and symptoms of great concern during the examination such as loss of consciousness, fracture of the skull, persistent vomiting and many other behavioural changes. Warning of a second impact syndrome, (Kirkwood MW et al., 2006) states that children should be kept away from play for a certain period, to minimize the risk of further fatal complications. Children suffering from a brain injury should be closely monitored before being allowed to return to sports. (Carroll LJ. et al. (2005)
The National Institute of Neurological Disorders and Stroke (NINDS) carry on extensive and intensive research in the area of TBI in the laboratories of the National Institute of Health (NIH). Also, it supports the research in TBI by offering grants to various distinguished medical institutions in the country. Research scientists work in these laboratories to find better interventions and strategies to help patients suffering from TBI by devising better methods to improve recovery.
Identifying the Degree of Damage
A head injury should not be taken for granted and treated lightly because further damage to the brain could occur. Therefore, immediate assistance is vital to prevent new catastrophe and result in a broad range of disparate outcomes. In the early stages of the recovery process, children identified with traumatic brain injury (TBI) are classified according to the degree of impaired consciousness after testing them on the Glasgow Coma Scale (GCS) (Anne Frances Cronin, (2000)
The head injury should be treated immediately to curb fatal complications. Research shows that vomiting recurrently is a good indicator of moderate to severe brain damage. Research has also shed light on the fact that little or no vomiting indicates that the child has suffered only a minor injury. According to the impact of the damage, necessary action should be taken to avoid further problems.
Research has also shown that since the brain of the child is still developing, any injury experienced by the brain could alter the course of development related to different functions. Though after a brain injury, the building blocks of learning are retained and made use of, in very young children, there are very few learning building blocks. Therefore they are prone to become disabled learners and may need special attention from the teachers as well as caregivers. Studies have also shown that the TBI effects may not surface directly after the injury, but could be seen in the course of the child’s development.
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