Head Injuries

How to assess if a head injury is serious

Try not to panic - call for help if someone is nearby. The features below will help you to assess how severe the head injury is, such as level of responsiveness, severe headache and memory loss.

Make sure there is no risk of further injury to yourself and the patient. Look for the following six features which will help give an idea of the severity of the head injury:

1. Did they blackout?
2. Is there a wound on the head?
3. Are they nauseous or dizzy?
4. Can they remember what happened before and during the injury?
5. Do they have a headache?
6. Are they confused?

In a severe head injury you may also find:

• They are less responsive. A simple way of checking this is using the AVPU scale. This stands for:
• A - Alert: Are they alert? Are their eyes open? Do they respond to questions?
• V - Voice: Do they respond to voice? Can they answer simple questions? Can they respond to instructions?
• P - Pain: If they are not awake or are not responding to you, try pinching them - do they move or open their eyes in response to the pain?
• U - Unresponsive: they are not responding to questions or a gentle shake or pain.
• If they can do all of the above then the head injury is likely to be mild but someone should still stay with them until they recover.
• There is blood or water-like discharge from ear or nose.
• The pupils are of different sizes.

What you need to do next

1. Press a cold compress or a packet of frozen peas wrapped in a towel at the site of the head injury.
2. If there is a cut on the head apply hand pressure to stop the bleeding.
3. Use the AVPU scale as above.
4. Call help if needed.

Call for an ambulance if:

• They are not improving.
• They have any of the serious features (under 'Should I be worried?', below).
• You are concerned about how alert they are or they are not responding normally.
• They are over 65 years of age.
• They have been drinking alcohol or using recreational drugs.
• They are taking medications which thin the blood (such as for blood clots).
• The injury was associated with loss of consciousness or blow to the head.
• There is a boggy scalp swelling (more than 5 cm size in children), which may indicate a part of the skull that is fractured and increased risk of brain haemorrhage.
• They have previously had brain surgery.

Should I be worried?

Minor head injury and knocks to the head are common, particularly in children. Following the injury, if the person is awake (conscious) and there is no deep cut or severe head damage, it is unusual for there to be any damage to the brain.

It is normal after a knock to the head to have a mild headache. Sometimes there is also tenderness over bruising or mild swelling of the skull bone.

However, sometimes a knock to the head can cause damage to the brain or to a blood vessel that surrounds the brain. A damaged blood vessel may bleed into the brain. This is uncommon but can be serious, as a build-up of clotting blood can cause pressure on the brain.

Symptoms of damage or bleeding may not develop for some hours, or even days, after a knock to the head. In rare cases, symptoms from a slow bleed can develop long-term even weeks after a head injury.

Symptoms of severe head injury

If you develop any of the following you need to seek immediate medical attention:

• Drowsiness when you would normally be wide awake (but see below).
• Worsening headache - which does not go away with paracetamol (but see below).
• Confusion, strange behaviour, and any problems with understanding or speaking.
• Inability to remember events before or after the head injury.
• Being sick.
• Loss of use of part of the body - for example, weakness in an arm or a leg.
• Speech difficulties.
• Dizziness, loss of balance or walking strangely.
• Fitting (convulsions) or collapse followed by feeling strange afterwards.
• Any visual problems, such as blurring of vision or double vision.
• Blood or clear fluid leaking from the nose or ear.
• New deafness in one or both ears.
• Unusual breathing patterns.

If none of the above is present, your doctor may still send you to be assessed in accident and emergency. Your doctor will do this if there are any concerns regarding the diagnosis, there is altered behaviour or irritability (particularly in children) or there is no one to be with you for the first 24 hours of the head injury.

A note about drowsiness

After a knock to the head, children will often cry, be distressed and then settle down. It is then quite common for them to want to sleep for a short while. This is normal. However, it will appear to be a normal 'peaceful' sleep, and they wake up fully after a nap.

Some parents are afraid to let their children go to sleep if the accident happens just before bedtime. Do let them. Drowsiness means they cannot be roused. If you have a concern, wake the child up after an hour or so. They may be grumpy about being woken up but that is reassuring. You can then let him or her go back off to sleep again. You can do this a few times during the night if there is particular concern. When asleep, check to see that he or she appears to be breathing normally and is sleeping in a normal position.

Some paracetamol or ibuprofen will help. It is a headache that becomes worse and worse which is of more concern.

What other symptoms of a head injury might occur?

Some people develop some mild symptoms after a head injury that are not serious and usually go away within two weeks. These can include:

• A mild headache.
• Feeling a bit sick without being sick (vomiting).
• Being irritable and grumpy.
• Tiredness.
• Poor appetite.
• Some difficulty concentrating.

These may develop just as a reaction to a knock on the head and not due to bleeding or serious injury. However, if you have any doubt about a symptom following a head injury then it is best to get it checked out by a doctor as soon as possible. Also, see a doctor if you feel that you have not completely recovered after two weeks.

Aftercare for a head injury

You may also need to review why the head injury occurred in the first place - for example, badly fitting shoes or loose carpet leading to tripping and falling.

Other head injury information which may be provided to you:

• Details of the injury and how severe it is.
• The need for a responsible adult to be with you for the initial 24 hours after their injury.
• How quickly you can expect to recover and what this is likely to involve. This will include when you can return to work or school. Some patients may develop complications later.
• Contact details of where to get further help if any complications occur.
• Available support organisations.

Some tips and other general advice following head injury

• Show a relative or friend this advice leaflet so they too know what symptoms to look out for.
• Stay within easy reach of a telephone and medical help for the following few days.
• Do not take any alcohol or recreational drugs for the following few days.
• Do not take sleeping tablets or sedatives unless prescribed by a doctor.
• You should use simple analgesia if needed.
• Discuss with your doctor about playing contact sports such as rugby or football. It is often advised that you should not play contact sports for three weeks following a head injury.
• Do not drive, do not ride a motorbike or bicycle and do not operate machinery until you feel completely recovered.