Waking Up After a Head Injury

A reader writes (about Head Injuries): "My son once fell on his head...and cried all the way home. When we got home he fell asleep from exhaustion....what does sleeping after a fall do?"

It is commonly taught that after someone has sustained a head injury with loss of consciousness (implying a concussion), that he or she should be kept awake. It is also taught that if the victim falls asleep, he should be awakened regularly, presumably to demonstrate that he can be woken up, and has not worsened or lapsed into a coma.

Where does this advice come from? Before the advent of computed tomography (CT) scans and magnetic resonance imaging (MRI), doctors could not easily get a radiographic look at the brain to determine if there was brain swelling or bleeding into or around the brain. A plain ("routine") X-ray of the skull only shows the bone. While it is important to see "the box," it's more important to see what is inside of it (e.g., the brain) - hence the importance of the CT and MRI technologies. So, prior to CT and MRI, many diagnoses were really estimates of what was going on inside the skull, not definite determinations. In order to determine if a victim of head injury was worsening, someone would need to perform a neurological examination ("neuro check") and keep track of the victim's mental and physical status. The frequency of these checks was fairly arbitrary, but sometimes would be as frequent as every 15 to 30 minutes. In most cases, once every hour or so would suffice. That would necessitate waking a sleeping patient.

Somehow, the concept that it was necessary to awaken a patient in order to perform a neuro check got transformed into the presumption that going to sleep was a bad thing to do after one suffered a head injury. That is not true. Sleeping in and of itself has no influence on the progression of the head injury. Furthermore, some persons who have suffered a concussion (or worse) become sleepy. If they fall asleep, they will not worsen because they fall asleep. If they worsen, it is part of the progression of the head injury, not related in any way to sleep. You cannot keep someone awake forever, because they need sleep to rest.

So, if you are in a situation where you are assessing someone who has suffered a head injury to determine their neurological status, you need to set reasonable intervals at which to perform the examinations. There is no magic number, but if you are concerned that someone is worsening, at least once an hour seems reasonable. Signs of worsening following a blow to the head include nausea and vomiting, blurred vision, increasing headache, and/or any change in mental status (e.g., declining alertness, ability to converse, or ability to follow commands; increasing confusion; or decreasing level of consciousness). If someone seems more sleepy than usual after a head injury, particularly if it is a child, perhaps difficult to assess and compounded with exhaustion, it is better to be safe than sorry. Bring that person to medical attention as soon as possible.

Tags: head injuries, concussion, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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