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May 6, 2009 > Head Injuries: Know When to Seek Emergency Care

Head Injuries: Know When to Seek Emergency Care

Injuries Vary in Severity, Lucid Intervals Rare

The sudden death of actress Natasha Richardson, after what appeared to be a relatively minor accident on a ski slope in Canada, left the public reeling. After all, how could someone stand up, hold a conversation and walk back to her hotel room, only to slip into a coma she would never wake from hours later?

It was later discovered that Richardson suffered an epidural hematoma.

"Simply put, an epidural hematoma is a collection of blood between the skull and the brain that is typically associated with direct trauma usually to the temporal area where the bone is particularly thin," according to Dr. David Orenberg, Medical Director of the Emergency Department at Washington Hospital.

"The meningeal artery is particularly close to the underside of the bone, and a direct fall or blow can result in tears to the artery that can cause a quick accumulation of blood. Whether there is significant deterioration in a patient depends on the size of the blood accumulation and how much pressure it causes on the brain."

A lucid interval - the period of time after the injury when the head trauma victim is awake and alert - is uncommon, Dr. Orenberg says.

Fewer than 20 percent of patients have a lucid interval before deteriorating. If patients are comatose or are suffering from seizures after trauma, the prognosis is not as good. Mortality in these cases can be as high as 45 percent, Dr. Orenberg says.

Head injuries, especially in young children, are a common occurrence in Washington Hospital's ER. But Dr. Orenberg cautions that there is a wide variety in the degree of severity.

"One of the more common head injuries we see in the ER is when a child falls while running and hits their head, sustaining a 'goose egg' swelling on the forehead or scalp," he explains. "That's a good example of an injury where if they didn't fall from a height such as stairs or a chair and they exhibit no vomiting, nausea, drowsiness, dizziness or behavioral changes, then parents can put ice on it and watch them. The swelling usually goes down quickly. If they do show signs of distress, then call 9-1-1. And certainly if they lose consciousness."

"Remember that kids obviously can't articulate when they have a severe headache. You have to watch for nausea, vomiting and drowsiness. I do let them sleep after head trauma, but I have the parents wake them and make sure the kids recognize them before allowing them to go back to sleep."

The most common causes of head trauma for adult and pediatric cases, he says, include motor vehicle and bicycle accidents and sports injuries.

"It's hard to know what the injury is when you're not a physician, and these cases can quickly deteriorate, which is why it's important to get attention if there are signs of severe trauma."

If 9-1-1 is called following a serious head injury, the responding paramedics typically assess the patient for potential neck injury before putting him or her on a board and cervical (neck) collar to avoid further injury. Patients might also be attached to an IV and given oxygen. When the patient arrives in the ER, the emergency medical staff will usually perform a computed tomography (CT) scan, which provides remarkable detail as far as injury to the brain and gives treating physicians a picture of the damage, according to Dr. Orenberg.

"It's really the collection of blood and contusion to the brain that we're looking for," he explains. "If somebody has a skull fracture and no bleeding, they'll usually do fine."

He gives the recent example of the San Francisco Giants pitcher Joe Martinez who suffered skull fractures and a subdural hematoma when a line drive hit him on the forehead. After a CT scan showed that internal bleeding had not worsened, Martinez was under observation, but did not require surgery.

As far as prevention, Dr. Orenberg says common sense precautions can go a long way. In freak accidents like that of Natasha Richardson, it's best to seek treatment at the first sign of trauma.

"I advise people to always use car seats when transporting young children," he says. "Helmets when bike riding or skateboarding are also a must. Another common sense measure is not drinking and driving. In the home, sometimes you can try to fall-proof your house. Make sure the stairs aren't slippery, make sure you're not going to trip over throw rugs and put non-slip adhesive in bathtubs to prevent falls."

In addition to young children, people over the age of 60 are also more susceptible to falls and should always seek medical attention.

"Patients older than 60 are at risk after a fall because their vessels are more fragile and often are on blood thinners," he says. "The same is true for people under the influence of alcohol because they don't know how hard they fell and dizziness or nausea can be confused with symptoms of intoxication."

In the case of serious head trauma, Dr. Orenberg points out that Washington Hospital has neurosurgeons on-call 24 hours a day.

To learn more about services and programs at Washington Hospital Healthcare System, visit and click on "Services & Programs." Select "Taylor McAdam Bell Neuroscience Institute" from the drop-down menu to learn more about treatment of conditions related to the brain, neck and spine.

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