“Whoa, man! What happened to you? Did you get in a fight with a ninja?” A little kindergartner enters the health office with a huge goose egg on his right forehead. “I bet you licked him, didn’t you?” Of course, without a frame of reference, the kinder looks at me sideways, kinda like a puppy who just heard a funny, squeaky sound.
“What’s that sound? You hear it? It’s a funny, squeaky sound.” – Aunt Bethany
It’s obvious that this child has hit or been hit in the head by something. And figuring out what “that” is takes a quick (yet temporary) backseat to performing the assessment to identify what the actual injury is and its severity. Let’s step back and review what that goose egg is telling us.
The goose egg is secondary. What I mean is: it’s on the outside of the skull. Swelling and bruising there, though a concern, is less of a concern than what may be going on within the skull itself. Swelling on the outside has room to move around and show off. A big ol’ goose egg is usually what makes the bump to the head “look” bad. Swelling on the inside is what makes a bump on the head…bad. A “goose egg” inside the skull is difficult to determine, given the short period of time and limited assessment tools for the school nurse. Rule number one when a child reports they have “bonked my head” is to assume there may be a concussion. That goose egg is telling us to do two things: that we need to treat the outside stuff (what we can see) and assess for the inside stuff (the stuff we can’t see and that may show up hours later).
What is a concussion?
A concussion is a brain injury that causing the brain to behave somewhat abnormally. It’s like dropping your laptop, and the screen freezes until you reboot it. The brain has just been “jolted” inside a closed cavity: the skull. And a concussion doesn’t always have to result from a bump to the head. Even falling and landing on your bottom or back can result in a concussion. After all, the fall is not what is causing the problems; it’s the sudden stop. This sudden stop causes to brain to move toward the direction of fall and then “bounce” back from that side of the skull and slam into the other side, kinda like a rubber ball. Often if you hit the back of your head on the ground, the front of the brain is injured.
Interesting:
In a year, traumatic brain injuries complications will cause the deaths of 3,000, hospitalize 29,000 and result in 400,000 ER visits. Get this: these numbers are for children younger than 15 years old.
Boys are twice as likely to suffer a traumatic brain injury than girls.
In our public schools, 13,000 children will end up needing health services beyond what we school nurses can offer (Youse, Le, Cannizzro and Coelho, 2002).
Individuals with Disabilities Education Act defines a traumatic brain injury as “…an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child’s educational performance…”
Bumps to the Head vs. Head Injuries
Because we are just reading an article and have lots of time to ponder stuff, let’s consider first that there is a difference between a bump to the head and an actual head injury. Most of what you see in your offices, on the playground, and in the school building are bumps to the head. If I bend over to put a dish in the dishwasher and, while coming up for the next dish I bump my head on the opened cabinet door, I likely have sustained a “bump on the head.” There are more assessment finding necessary to determine that an actual head injury has occurred. After all, the bump that I got when I stood up may very well be an actual head injury. Likely I will shout, “Papapishu!” and rub the spot on my head that smarts. But, what if weird concussion symptoms (that we’ll discuss later) began to show up? As a school nurse who is responsible for the little people, what steps will we take to get a better idea of what’s going on inside that little person’s head, and what steps to take if we feel something is wrong?
“I bonked my head.”
You will either see the child come to your office crying or even giggling about the head bump, or you may be called to the location where the incident has occurred because the teacher or other faculty member feels the child should not be moved (good teacher…wise teacher). If a child has come to your office and reports having bumped (or bonked) their head (without bleeding or other open areas), have the child sit and hold an ice pack on the area. Sitting still is the best bet. Some of those kids can really “take one” to the noggin and be moving around like nothing happened. Nonetheless, they could be hurt in less-than-obvious places, despite the child’s demeanor or how they present.
If the child is on the playground or in the classroom when a bump to the head occurs, you may be called to the location. Even before assessment and first aid are initiated, your goal is to minimize head movement. All suspected head injuries (even those who show up to the health office) should be treated as though there is an injury to the neck or spinal cord, pure and simple. If you think for even a moment that the child has some spinal involvement, brace that little person’s head with your hands or by squatting over their head and using your inner thighs to support their little head. There are other measures, but these two will get you started.
Assess for scrapes, cuts, red areas, and developing goose egg