Head Injury Symptoms: When to Seek Medical Care

Medical Author: Benjamin C. Wedro, MD, FACEP, FAAEM
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR

Natasha Richardson, an acclaimed actress, was apparently taking a ski lesson outside of Montreal, Canada, when she seemingly had a relatively minor fall and hit her head. Over the next hour, she complained of increasing headache, was taken to a local hospital and by all reports was critically ill in a New York hospital, until it was announced Ms. Richardson had passed away from the head trauma she suffered.

The type of brain injury she sustained was revealed as an epidural hematoma. An epidural hematoma occurs when there is bleeding between the dura mater (a tough fibrous layer of tissue between the brain and skull) and the skull bone. These occur when arteries are torn as a result of a blow to the head, and injury in the temple area is a common cause. Although the pattern of a lucid interval followed by later neurological symptoms is characteristic, only a minority of patients display this pattern of symptoms. Reported death rates from epidural hematoma vary widely, ranging from 5% to over 40%, depending upon the patient population under study.

To begin understand how something like this can happen, let's review the serious topic of minor head trauma and the potential that it has to become major head trauma.

Minor head injuries are defined as those where trauma causes a temporary loss of mental function, however, there is still a potential risk that something bad might happen. In fact, there are numerous guidelines to help physicians decide who might need a CT scan to look for brain bleeding or injury. The February 2009 edition of the Annals of Emergency Medicine contained an article that compared six different sets of guidelines. The conclusion was that each worked equally well in predicting who may or may not have bleeding in the brain. If the symptoms were not present, then it was safe to reassure the patient and family and let them go home. If symptoms were there, a CT scan was needed to look for brain damage.

Often, the injury that causes brain damage may not be dramatic or very traumatic, and the person may not initially lose consciousness. But for those few, where the head is hit in just the right place with just the right amount of force, the potential for swelling in the brain is real.

The New Orleans Criteria found seven symptoms that suggest when to obtain a CT scan. These same seven symptoms are reasonable as a guide to seek medical attention after a head injury:

1. Headache
2. Vomiting
3. Short term memory loss
4. Alcohol intoxication
5. Seizure
6. Physical evidence of trauma to the head or neck
7. Age over 60

Other guidelines would add dangerous mechanism of injury such as being hit by a car or falling down steps, and being on a blood thinner like warfarin (Coumadin) or clopidogrel bisulfate (Plavix).

Head injuries are all too common, with almost 250,000 admissions to hospitals in the US each year and an estimated 50,000 deaths. Car wrecks and sports injuries account for up to 90% of these injuries. Kids aren't immune - with over 2,500 deaths each year in children under the age of 14.

Unfortunately, the epidural hematoma Ms. Richardson's suffered it seems, was a result of the trauma that was relatively major and she was supremely unlucky. The ski patrol who evaluated her and the ski instructor who reportedly stayed by her side, seemed to follow the guidelines by getting her to the hospital when Richardson's headache began. It is unfortunate that even when things are done right, the outcome can be so tragic.

References: Stiell IG, et al. The Canadian CT head rule for patients with minor head injury. Lancet May 5, 2001;357:1391-6.
Haydel MJ, etal. Indications for Computed Tomography in Patients with Minor Head Injury. NEJM2000;343:100-5
emedicine.com; "Epidural Hematoma," January 31, 2008