Legal nurse consultants may be asked to work on cases involving the pediatric population & head injuries. In the pediatric population, head injuries account for approximately 475,000 visits to emergency departments (ED) in the United States. Of those, more that 75% are considered mild traumatic brain injuries (Babcock, L. 2013).
Data from emergency room visits collected by the CDC from 2002-2006 show that over 50% of mild traumatic brain injuries from birth to 14 year of age are caused from falls (Faul et al., 2010). Download it traumaticbraininjury.
The pediatric population & head injuries – “I’ll dare you”
Older pediatric patients, especially adolescents, tend to engage in risk taking behavior with greater risk of injury. For instance, the child was dared by friends to jump off of a roof and land in a pool, but instead hit the diving board on the way into the water.
Does the description of how the head injury occurred make sense?
The nurse should question the child and caregiver of the events surrounding the injury, including if it was a witnessed fall, if there was seizure activity after the fall, and if there was loss of consciousness with the fall. The nurse should obtain as much information from the patient and caregiver or witnesses as possible in order to get a complete picture of the incident.
The standard of care for triaging in the ED remains as high as if treating an adult with a head injury but with important differences. (Go to the link for part 1 of this topic.)
The nurse must look at the whole picture of the incident in order to get a sense of the events surrounding the injury. In the pediatric population & head injuries, the events or story surrounding the fall and subsequent injury must be consistent with the actual injury. The story of the caregiver must be consistent with injuries observed.
The nurse needs to look at the interaction between the child and caregiver. If the child is crying, can the caregiver comfort the child or does the caregiver’s touch make the child flinch? If any events or the story surrounding the events set off any red flags to the treating nurse, a call to the state’s child welfare authority should be undertaken by the nurse as the advocate for the child.
The attending physician should be made aware of the nurse’s concerns so that the appropriate radiologic and CT scans are to be ordered to detect any old injuries on the patient. Security at the facility should be contacted as a standby in case the caregiver decides to leave with the child prior to discharge.
Protective care of the head injured child
A child who has fallen and hit his head should be observed for neck and spinal injury. A hard cervical collar should be placed on the patient. If the injury was significant, the child should be placed on a backboard until he is deemed medically stable by the physician to come off of the board.
The child should be observed for age appropriate cognition, speech, and behavior. The standard of care for the head injured child is a head CT, which can rule out any hemorrhagic occurrence in the brain. Most children will be diagnosed with a concussion, which can have short or long term ongoing symptoms, depending upon the severity of the injury. Follow up care for the child with a minor head injury should include post concussive syndrome information and education on what to expect in the days and months following a concussion.
Veronica Manlove MSL RN CEN is a certified emergency department nurse and expert witness with 20 years of inner city emergency department clinical experience. She is President, Legal Nurse Consulting, LLC. She received a Master of Science in Law from Champlain College in 2010 which she uses in combination with her clinical background as a legal nurse consultant.
Babcock, L., Byczkowski, T., Wade, S. L., Ho, M., Mookerjee, S., & Bazarian, J. J. (2013). Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA pediatrics, 167(2), 156-161.
Faul, M., Likang, X. , Wald, M.M., & Coronado, V.G. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths 2002-2006. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.