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Feature Article

Head Injuries in Children

Nicole Pennington, MSN, RNC

School nurses play a crucial role in injury prevention and initial treatment when injuries occur at school. The role ofschool nurses includes being knowledgeable about the management of head injuries, including assessment andinitial treatment. The school nurse must be familiar with the outcomes of a head injury and know when furtherevaluation is indicated. Developing a head injury protocol in the school setting is one strategy to make sure thatall involved are able to consistently and effectively respond to a head injury and prevent a possible negativeoutcome. The combination of a protocol, nursing judgment, and best practices can ensure that all means areused to take care of children when a head injury is sustained. These strategies will help to increase the safety ofchildren at school. A systematic approach to the management of these types of injuries is essential forpreventing possible complications.

Keywords: injuries; physical assessment; best practices/practice guidelines; documentation; standards of care

INTRODUCTION

Hippocrates once said, ‘‘No head injury is tootrivial to ignore’’ (Aloi, Rempe, & Santamaria,2008). His advice still holds true today for schoolnurses who assess head injuries that occur atschool. Whether it is a collision in the hallway, afall from the monkey bars, or running into a wall,all head injuries need to be assessed, treated,documented, and communicated. Being knowl-edgeable about the management and treatmentof head injuries is important for school nurses.A prompt and accurate assessment has the poten-tial to prevent potential negative outcomes. A sys-tematic approach to the management of thesetypes of injuries is essential for preventing possiblecomplications. The use of a head injury protocol inthe school setting can help assure that these typesof injuries are consistently and effectivelyresponded to at school. Knowing what potentialoutcomes can result and when further evaluationis indicated is critical to optimizing outcomes forstudents with a head injury (Cobb & Battin,

2004). Using a protocol, sound nursing judgment,and best practices are strategies that help ensurethat head injuries are properly attended to atschool. These strategies will help ensure the safetyof children when a head injury occurs at school.

LITERATURE REVIEW

Injuries that occur in the school setting are asignificant contributor of pediatric injury in theUnited States. This has been attributed to theamount of time that children spend at school(Josse, MacKay, Osmond, & MacPherson,2009). In the United States, school-related inju-ries account for 10�25% of pediatric injuries,resulting in nearly 3.7 million injuries in American

Nicole Pennington, MSN, RNC, is an assistant professor ofnursing at Ohio University, Southern Campus, Ironton, Ohio.

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schools annually. Research indicates that childrenare more likely to sustain a head injury at schoolthan at other location, and there is an increasedrisk of this type of injury in autumn. Most headinjuries at school occur in recreational areas, suchas playgrounds or athletic fields, followed by class-rooms and cafeterias. The next most commonlocation for unintentional and intentional headinjuries is in passing areas, such as hallways andstairs (Limbos & Peek-Asa, 2003).

‘‘In the United States, school-related injuries accountfor 10�25% of pediatric injuries, resulting in nearly3.7 million injuries in American schools annually.’’

The American Academy of Pediatrics (AAP)Committee on School Health and the AmericanHeart Association have published guidelinesrecommending improving the training for schoolnurses so that they can rapidly and accuratelydetermine the status of ill or injured children,provide lifesaving interventions, and evaluatethe effectiveness of treatment (Olympia, Wan, &Avner, 2005). An important barrier that has beenidentified in schools when dealing with emergencyresponse is the lack of school nurse availabilitywhen scheduled for only a portion of the schoolday. Although there are usually school staff mem-bers trained in dealing with emergencies, researchhas found that they lack confidence in respondingto emergency situations (Olympia et al., 2005).

Elementary schools have the highest rates ofreported injuries, followed by high schools, andthen middle schools. Males have significantlyhigher numbers of reported injuries than females(Singh & Stock, 2006). Previous research indi-cates that reported school injuries resulted intrauma to the head, face, or neck. The leadingcauses of reported unintentional injuries are falls,followed by being struck by or colliding with anobject or another student. Most school intentionalinjuries in elementary schools are the result ofbeing pushed or shoved by another student.Bernardo, Gardner, and Seibel (2001) report thatamong middle and high school students, mostintentional injuries are caused by physical fight-ing. Research indicates there is little difference

in the time of occurrence during the school day forintentional or unintentional injuries, making itdifficult to determine the best time of day for aschool nurse to be present or for school monitor-ing to be in place (Limbos & Peek-Asa, 2003).

In the United States, head trauma represents80% of the injuries that lead to death in childrenolder than 1 year of age (Bayreuther & Macono-chie, 2008; Singh & Stock, 2006). Pediatric headtrauma is common and can range from minor tosevere. Most head injuries in children are mildand not associated with brain injury or long-term problems (Da Dalt et al., 2006). Accordingto the National Center for Health Statistics, themortality rate from head trauma is 29% in thepediatric population. Data reported by traumacenters show that head injuries represent75�97% of pediatric trauma deaths. Of the chil-dren with moderate-to-severe head injury,10�20% have short-term memory problems anddelayed response times (Singh & Stock, 2006).Occult lesions and delayed intracranial compli-cations have been reported in up to 17% of chil-dren with apparently trivial head injuries,emphasizing the importance of a thoroughassessment by school nurses (O’Hebb, Clarke,& Tallon, 2007).

‘‘In the United States, head trauma represents 80% ofthe injuries that lead to death in children older than

1 year of age.’’

HEAD INJURIES

Head injuries fall into two main categories—external and internal (Singh & Stock, 2006).External head injuries include scalp injuries, andinternal injuries may involve the skull, blood ves-sels within the skull, or the brain. Most childhoodfalls or blows to the head result in injury to onlythe scalp, which is usually more frightening thanthreatening. The scalp is rich with blood vessels,and so even a minor cut can lead to profuse bleed-ing. However, an internal head injury could havemore serious implications, because the skull servesas the protective casing for the brain. Although

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the brain is cushioned by cerebrospinal fluid, asevere blow to the head may knock the brain to theside of the skull or tear the blood vessels. Anyinternal injury, a fractured skull, torn blood ves-sels, or damage to the brain can be serious andpossibly life threatening (Da Dalt et al., 2006).

Different levels of head injuries require differ-ent levels of concern (O’Hebb et al, 2007). A clearindicator that a child has sustained a more serioushead injury is when there is a loss of consciousness(LOC) or sign of confusion. The National Insti-tute for Health and Clinical Excellence (NICE)provides guidance for triage, assessment, investi-gation, and early management of head injuries ininfants, children, and adults. The signs and symp-toms listed in Table 1 are indicators that furtherevaluation is warranted following a head injury.

CONCUSSION

A concussion is a form of head injury thatoccurs immediately after a blunt force strikes thehead causing the brain to move within the con-fines of the skull (Purcell & Carson, 2008). Thesigns of brain injury may include headache, visualdisturbances, gait disturbances, and LOC. LOCoccurs in approximately 10% of concussions; how-ever, LOC does not always predict the severity ofoutcomes from concussions (Cobb & Battin,2004). Confusion and/or LOC are common signsthat have been found to be more predictive ofpostinjury deficits, including cognitive deficits.These major symptoms and their duration are

used in concussion grading systems to help deter-mine the severity of closed-head injury. A grade 1concussion is indicated by transient confusion withmental abnormalities lasting less than 15 min butwith no LOC. A grade 2 concussion is indicatedby a transient confusion with mental abnormalitieslasting 15 min or more but with no LOC. A grade 3concussion is indicated by an LOC. Any studentpresenting with signs and symptoms of a concus-sion should be referred to a physician for evaluation(Purcell & Carson, 2008). Should this type of injuryoccur outside school, it is important the schoolnurse is informed so the student can be monitoredin the school setting.

ASSESSMENT OF HEAD INJURIES

A detailed assessment of any head injury isessential to identify neurological status (O’Hebbet al., 2007). Because any head injury has thepotential to be catastrophic, the initial assessmentis critical. After mild head trauma, symptoms maygo unrecognized or be misinterpreted. The criteriafor assessing head injuries have been developedfrom various studies over the years. Diagnosticcriteria classify head injuries as mild, moderate,or severe. Specific signs and symptoms for eachcategory are indicated in Table 2.

The assessment should include checking for thepresence of headache, nausea, vomiting, dizzi-ness, coordination, blood pressure, heart rate,pupil reactions, LOC, and mental confusion.Children have a higher metabolic rate, resultingin slightly higher respiratory rates when comparedwith adults. Pulse rates in children should notexceed 120. Pain and anxiety will increase pulseand respirator rates. Their blood pressure may notdrop until they have lost 45% of their bloodvolume (Dunning, Daly, & Lomas, 2007).

Specific assessment of mental status shouldinclude checking mental orientation, ability toconcentrate, memory, and duration of memoryloss or disorientation (Mailer, McLeod, & Bay,2008). The orientation assessment should includeknowledge of date, place, person, and situation.Concentration can be assessed by asking the childto count backward or repeat a common saying,and memory can be assessed by asking the childto name his or her favorite teachers or how he orshe got to school that day. To assess neurological

TABLE 1. Indicators that Warrant Further Evaluation

� Unconsciousness� Abnormal breathing� Obvious serious wound or fracture� Bleeding or clear fluid from the nose, ear, or mouth� Disturbance of speech or vision� Pupils of unequal size and/or delayed reaction to light and

accommodation� Weakness or paralysis� Dizziness� Neck pain or stiffness� Seizures� Vomiting� Loss of bladder or bowel control� Irritability or other unusual behavior� Stumbling or difficulty walking� Confusion� Unusual paleness that lasts for more than an hour

28 THE JOURNAL OF SCHOOL NURSING



status, check the child’s strength, coordination,agility, and sensation. Abnormal findings, suchas headache, dizziness, nausea, photophobia,blurred or double vision, emotional liability, ormental status changes, need further assessmentby a physician.

The Glascow Coma Scale (GCS) is a tool thatcan be used to assess pediatric head injuries (Kirk-ham, Newton, & Whitehouse, 2008). This scalewas developed to assess acute, global neurologicstatus following a head injury. It correlates withinjury severity and guides prehospital and earlyresuscitation interventions. Serial GCS scoresprovide insight into overall trajectory andresponse to treatment (Da Dalt et al, 2006). Thisscale assesses eye opening, verbal response, andmotor function. The scale is the most widely usedmeasure of neurological function in the presenceof a head injury and has significant prognosticvalue. The pediatric coma scale is a modified ver-sion of the original scale and can be used onyounger children (Table 3; Abelson-Mitchell,2008). Generally, the pediatric coma scale is usedas an assessment tool for children 16 years andyounger. A score of 13�15 is indicative of a minorhead injury, and a score of 3�12 is indicative of amajor head injury. The GCS does not measurecommon symptoms of head injury such as vomit-ing, irritability, or subtle changes in alertness.Therefore, it is possible that some children witha GCS score of 13�15 could have clinical signsof head trauma not assessed by GCS (Arbogast,Marguilies, & Christian, 2005).

Among children with a significant head injury,two thirds have no other significant trauma.NICE updated the guidelines in 2007 (PediatricNursing, 2007). These updates provide guidanceon the Pediatric GCS (Bayreuther & Macono-chie, 2008).

HEAD INJURY PROTOCOL

Fortunately, most head injuries at school areminor and do not require transport to the hospital(Da Dalt et al., 2006). The scenario is usually onein which a child is brought to the school healthoffice because he or she ‘‘hit his or her head’’. Itis what happens next in the assessment and imme-diate treatment that can make an important dif-ference in the outcome of a pediatric head injury.

Step 1 of the head injury protocol (Table 4)should be the detailed physical assessment andimmediate care of the head injury (Bobo, Hallen-beck, & Robinson, 2003). As part of the assess-ment, the child should be asked how the injuryoccurred; this should be verified with witnessesin case of altered mental status. If any life-threatening warning signs are identified, 911should be notified immediately. If a laceration orabrasion is present, the site should be gentlycleansed with antibacterial soap and water. Ifappropriate, a cool compress or ice pack to theinjury site can be applied for comfort.

Step 2 of the protocol should include notifica-tion of parents and the classroom teacher. Par-ents should always be notified by phone toinform them that a head injury has occurred.Should the student exhibit any of the previouslymentioned warning signs, parents should be noti-fied to seek medical treatment. Reporting andcommunicating is an important step in everyhead injury situation. School nurses can use ahead injury letter (Table 5) to document theevents; a copy of this letter should be given to theparent and teacher. An illness/injury reportshould be completed and kept on file in theschool health office (Table 6).

Step 3 of the protocol should be the procedureto follow for sending a student back to the

TABLE 2. Diagnostic Criteria for Traumatic Brain Injury

Symptom Mild Moderate Severe

Loss of consciousness None or less than 30 min 30�24 hr Exceeds 24 hrPosttraumatic amnesia None or less than 60 min 1�24 hr Exceeds 24 hrAlteration of mental status at time of accident May/may not be present Yes YesFocal neurological deficits May/may not be present Yes YesGlascow Coma Scale (GCS) 13�15 9�12 3�8

From ‘‘Clinical criteria predict serious head injury risk in kids,’’ by J Dunning, J. Daly, and J. Lomas, 2007, Journal of Family Practice, 56,16-17. Adapted with permission of the author.




TABLE 3. Glascow Coma Scale for Children

Eye Opening Score

Spontaneously 4To verbal stimuli 3To pain 2Never 1Total score for eye opening

Nonverbal Child Verbal Child’s Best Verbal Response (Glasgow coma scale) ScoreSmiles, oriented to sound, follows objects, interacts oriented and converses 5Consolable when crying and interacts inappropriately disoriented and converses 4Inconsistently consolable and moans; makes vocal sounds inappropriate words 3Inconsolable, irritable and restless; cries incomprehensible sounds 2No response no response 1Total score for verbal response

Best Motor Response Scoreobeys commands 6localizes pain 5flexion withdrawal 4abnormal flexion (decorticate rigidity) 3extension (decerebrate rigidity) 2no response 1Total Score for Motor Response

Total Score ________________Interpretation:� minimum score is 3, which has the worst prognosis.� maximum score is 15, which has the best prognosis.� Scores of 7 or above have a good chance for recovery.� Scores of 3-5 are potentially fatal, especially if accompanied by fixed pupils or absent oculovestibular responses or elevated intracranialpressure.From ‘‘Paediatric coma scales,’’ by F. Kirkham, C. Newton, and W. Whitehouse, 2008, Developmental Medicine & Child Neurology, 50, 267-274. Adapted with permission of the author.

TABLE 4. Head Injury Protocol

Step 1: Assessment and Immediate CareAsk child and witness how injury occurred.Vital Signs: T-________P- _________R- _________B/P-__________Pupillary Response: _______________________________________________Presence of Headache: __________Yes __________NoPresence of Nausea/Vomiting: ___ Yes __________NoLoss of Consciousness: _________ Yes __________ NoAlteration in orientation: ________ Yes __________ NoAlteration of Vision: ___________ Yes __________ NoGlascow Coma Scale Score—initial assessment: ____________Glascow Coma Scale Score—15-min follow-up assessment: ____________Glascow Coma Scale Score—30-min follow-up assessment: ____________Cleanse abrasions/lacerations with antibacterial soap and water.Step 2: Notification of ParentsNotify parents by phone and inform them of the injury, the child’s assessment state, and care provided. Review warning signs to watch forfollowing a head injury. Inform them that you will be sending a head injury letter home.Step 3: Notification of Classroom TeacherNotify classroom teacher in person or by phone if child will be returning to the classroom so that observation can continue when the child is inclass for the remainder of the school day. Provide the teacher with a copy of the head injury letter.Provide the child with a head injury sticker to wear so that everyone is aware that a head injury occurred as this can provide for a reminder towatch for signs and symptoms of complications.




classroom. If the child returns to class followinghead injury, the teacher should be given a copyof the letter with specific instructions on what towatch for in relation to the head injury. One copyof the head injury letter should be sent home withthe student. Stickers that say, ‘‘Please watch me, Ihit my head today!’’ can be purchased or made(Figure 1). The young student can wear thissticker back to class and home so that everyonethey come in contact with is aware that the childhad a head injury at school.

This three-step protocol provides a thoroughsystem of assessment, care, and communication,which will provide for the safety of children whenthey have a head injury at school.

‘‘The school nurse’s role in prevention can occur byincreasing the awareness of playground safety andsupervision, providing education on helmet safety,

and car seatbelt safety. School nurses play a crucialrole in injury prevention.’’

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

The school nurse’s role in prevention can occurby increasing the awareness of playground safetyand supervision, providing education on helmetsafety, and car seatbelt safety. School nurses play

TABLE 5. Head Injury Letter

Date/Time of Injury ____________________Dear Parent/Guardian:Today, ___________________________ was seen in the school office and was given emergent treatment only. This treatment is not intended tobe a substitute for complete medical care. It is important that you use your own judgment in determining whether you contact your familyphysician and/or have your child examined in the emergency room if your child’s injury warrants further care. Your child did not experienceany problems at the time they reported to the office, but you should watch for any of the following symptoms:1. Severe headache2. Excessive drowsiness (awake the child at least twice during the night)3. Nausea and/or vomiting4. Double vision, blurred vision, or pupils of different sizes5. Loss of muscle coordination, such as falling down, walking strangely, or staggering6. Any unusual behavior such as being confused, breathing irregularly, or dizziness7. Convulsions8. Bleeding or discharge from the ear

Contact your local physician or emergency room if you notice any of the above-mentioned symptoms.If your child plays any contact sports, please inform coaches or adult supervisors that your child did sustain a head injury at school and explainwarning signs to watch for.An accident report has been completed.Injury details: ________________________________________________________Treatment given: _____________________________________________________Suggestions: _________________________________________________________School Principal/Nurse/Secretary _______________________________________

TABLE 6. Illness/Injury Report

ILLNESS/INJURY REPORTDate: _________________ Time: __________ School: _________________Student: ________________________Witnesses/Phone Numbers: __________________________________________________Circle One: Injury/Location __________ Illness/Other/Home Visit _________Temp_________________________________________________Intervention:_____________________________________________________________________________________________________________Comments &/or Evaluation:________________________________________________________________________________________________Parents Notified: Yes/No Time Contacted: ______________________________Student sent back to class: Yes/No Time returned to class: _________________________Student sent home: Yes/No Time picked up by parent: ______________________Form Completed By: __________________________ Title _________________________




a crucial role in injury prevention. By recognizingthe unsafe practices, school nurses can documentand bring to attention the importance of safe play-ground behavior to administrators, staff, parents,and children (Hudson, Olsen, & Thompson,2008). Prevention programs should be targetedlargely toward elementary school students becausethere is an age relationship with respect to the like-lihood of being injured at school (Josse et al.,2009). Passenger seatbelts and airbags may be use-ful in preventing head injuries, and children shouldsit in appropriate booster seats as indicated by ageand seated in the back seat if under the age of 12.Helmets should be used by children and adoles-cents during certain sporting events to reduce therisk of head trauma (Singh & Stock, 2006). Reduc-ing school-related injuries will promote a safe andsecure learning environment for students whilereducing health-care expenditures for preventablechildhood trauma (Josse et al., 2009).

CONCLUSION

Whether it is a head-on collision in the hallway,a fall from the monkey bars, or running into awall, all head injuries need to be assessed, treated,documented, and communicated. The processespresented have the potential to help ensure thesafety of children when head injuries occur atschool. A systematic approach to the manage-ment of head injuries is essential for preventingpossible complications. School nurses play a cru-cial role in injury prevention and initial treatment,when head injuries occur at school. The early

identification and treatment of a head injury canimprove clinical outcomes (Bayreuther & Maco-nochie, 2008). The role of school nurses includesbeing knowledgeable about the management ofhead injuries, including assessment, initial treat-ment, communication, and reporting.

REFERENCES

Abelson-Mitchell, N. (2008). Epidemiology and prevention of headinjuries: Literature review. Journal of Clinical Nursing, 17, 46-57.

Aloi, M., Rempe, B., & Santamaria, J. (2008). Pediatric concussions.Emergency Medicine Reports, 29, 1-12.

Arbogast, K., Marguilies, S., & Christian, C. (2005). Initialneurologic presentation in young children sustaining inflictingand unintentional fatal head injuries. Pediatrics, 116, 180-184.

Bayreuther, J., & Maconochie, I. (2008). The evidenced-based carebehind the early management of head injured children. Trauma,10, 85-92.

Bernardo, L., Gardner, M., & Seibel, K. (2001). Playground injuriesin children: A review and Pennsylvania Trauma Centerexperience. Journal of the Society of Pediatric Nurses, 6, 11.

Bobo, N., Hallenbeck, R., & Robinson, J. (2003). Recommended min-imal emergency equipment and resources for schools: Nationalconsensus group report. Journal of School Nursing, 19, 150-156.

Cobb, S., & Battin, B. (2004). Second-impact syndrome. Journal ofSchool Nursing, 20, 262-267.

Da Dalt, L., Marchi, A., Laudizi, L., Crichiutti, G., Messi, G., &Pavanello, L, et al. (2006). Predictors of intracranial injuries inchildren after blunt head trauma. European Journal of Pediatrics,165, 142-148.

Dunning, J., Daly, J., & Lomas, J. (2007). Clinical criteria predictserious head injury risk in kids. Journal of Family Practice, 56,16-17.

Hudson, S. D., Olsen, H. M., & Thompson, D. (2008). An investiga-tion of school playground safety practices as reported by schoolnurses. Journal of School Nursing, 24, 138-144.

Josse, J., MacKay, M., Osmond, M., & MacPherson, A. (2009).School injury among Ottawa-area children: A population-basedstudy. Journal of School Health, 79, 45-50.

Kirkham, F., Newton, C., & Whitehouse, W. (2008). Paediatric comascales. Developmental Medicine & Child Neurology, 50, 267-274.

Limbos, M., & Peek-Asa, C. (2003). Comparing unintentional andintentional injuries in a school setting. Journal of School Health,73, 101.

Mailer, B., McLeod, T., & Bay, R. (2008). Healthy youth are reliablein reporting symptoms on a graded symptom scale. Journal ofSport Rehabilitation, 17, 11-20.

O’Hebb, M., Clarke, D., & Tallon, J. (2007). Development of a pro-vincial guideline for the acute assessment and management ofadult and pediatric patients with head injuries. Canadian Journalof Surgery, 50, 187-194.

Olympia, E., Wan, E., & Avner, J. (2005). The preparedness ofschools to respond to emergencies in children: a survey of schoolnurses. Pediatrics, 116, 738-745.

Purcell, L., & Carson, J. (2008). Sport-related concussion in pediatricathletes. Clinical Pediatrics, 47, 106-113.

Singh, J., & Stock, A. (2006). Head trauma. eMedicine Pediatrics.Retrieved February 15, 2009, from http://emedicine.medscape.com/article/907273-print

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Figure 1. Sample head injury sticker. From http://www.smile-makers.com. Retrieved February 15, 2009.




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