Now that I (and Ellie) have recovered from the initial shock of last week's head injury, blue spell, and grand mal seizure, I am finally able to sit down and actually write a more informative post about head bonks, post-fall seizures, c-spine precautions and atlantoaxial instability [AAI], and about remembering to list Down syndrome as a medical diagnosis.
Head bonks happen. Children fall off changing tables. They fall down stairs. They climb over baby gates. They scale walls. . . oh wait, is that just Ellie? Anyway, falls happen. It is a part of being a child. A right of passage into toddlerhood. Wipe away the mama guilt and the feelings of inadequacy. It happens. We cannot hover over our children with outreached arms 24/7. It is not humanly possible. Plus, there is that ever-so fine line of allowing your child to explore. To gain independence. Besides, that is what bubble wrap is for.
So we have established that kids fall. The question is, when do you go to the pediatrician or even the ER? If I took Ellie to the ER every time she bonked her head, we would be there every single day. Literally. I am not exaggerating. Those who have met my spunky Ellie know that I am not kidding.
Signs your child needs to be seen by a health care provider after a fall:
- Loses consciousness
- Stops breathing
- Unequal pupils-the dark centers of the eyes should be equal size and get smaller when light is shined into the eyes.
- Convulsions or seizures
- Vomits more than once
- Lethargy, difficultly arousing
- Blunt trauma / open wound /profuse bleeding that does not stop
- Difficulty walking or unequal movement of limbs
- Bleeding or clear fluid draining from the ears
- Slurred speech
Please note that the above signs may not occur immediately after the fall. You want to watch your child closely for the first 24 hours. If your child is due for a nap or it is close to bedtime, be sure to check on her frequently for the first few hours to make sure she is breathing okay, no color changes, and is arousable.
If she is unconscious, try not to move her in case her neck suffered an injury. With vomiting and/or seizing, carefully place her on her side, but try to keep her neck stable (yeah, I know, it is easier said than done. With Ellie, I did not do such a great job on the stabilizing). With seizing, do NOT attempt to place anything into the her mouth.
If an object is lodged into your child's head (scary, I know!), do NOT remove it. Yes, yes, I know you want to remove it and if your child is conscious, I am sure that she is trying to remove it as well. Keep your cool and leave it in because removing it yourself may cause further damage.
Finally, when in doubt, trust that mama gut of yours and call the pedi. If your child seems off to you or things just do not seem right, it takes just seconds to contact the pediatrician and ask to speak with the nurse as she can guide you.
Which happened first? Seizure vs. Fall
For Ellie, it was quite obvious. She fell. She screamed for a minute. Then she had a tonic clonic/grand mal seizure--full body rhythmically jerking (this is the same type of seizure Ellie had during a high fever). However, in some cases the kiddo seizes and it is the seizure that caused the fall. Occasionally, it is difficult to answer the question of which came first because the seizure appears to happen immediately upon hitting the floor or because the fall is not observed.
Then there are those tricky absence seizures. The child appears to be staring into space. There may be mild twitching of the mouth or lip smacking. The eyes may shift. Additionally, atonic seizures produce an sudden loss of muscle tone. The child just falls to the ground or her head suddenly drops. Unless you are familiar with these types of seizures, they are hard to detect. Nonetheless, a child may be hanging out on the monkey bars and seems to be paused in mid air and then falls. Is she planning her next move or is she having a seizure?
Many times, children who endure many falls accompanied with seizing are evaluated for a seizure disorder. Tests such as EEGs and CT/MRI scans may assist in diagnosing seizures and there are several medications that can help control seizures.
Above, I mentioned three types of seizures-grand mal, atonic, and absence. There are several types of seizures and more information can be found HERE.
Why it is important to list Down syndrome as a medical condition and in the past-medical-history:
You have heard me say it again and again "My daughter is not Down syndrome. She is a child who happens to have Down syndrome". That still holds true, however, the fact remains that Down syndrome is a major part of her genetic make-up and there are several physiologic traits that my daughter possesses as a result of her designer genes. The main ones being low muscle tone, loose ligaments, and small airways. For some children, their list may include holes in the heart, hypothyroidism, or a history of heart surgery. These are important to know if your child is injured. Moreover, if your child is ill (as in heading to the ER for something other than a fall), mentioning that your child has Ds helps the doctor zoom in on certain illnesses such as heart issues/infections, thyroid issues, diabetes, Hirsprung's disease, and leukemia.
Surprisingly, many health care providers may not even recognize that your child rocking an extra chromosome. At 7 months old, I took Ellie to the ER for anaphylaxis. She was hanging out with a hole in her heart, serious reflux, and, well, anayphylaxis. The triage nurse did not realize Ellie had Down syndrome. She just brushed past the medical history and said "no health issues" and proceeded to tell me that she is fine. Meanwhile, my daughter's lip and throat were closing. Being the mama bear that I am/was, I shoved Ellie's medical binder at her and said "she needs to be seen now! she does have complex medical issues and this cannot wait". The doctor got it, BUT the receptionist and then the nurse--the first two people you must get past to see the doc did not recognize Ds.
The same held true for our most recent ER trip. The EMS had no idea. It was up to me, as her mother, to state that Ellie had Ds and that as such she also has low muscle tone and needs C-spine precautions. They assumed that my daughter was "a baby" because she is small when in reality she is 3.5 years-old! C-spine precautions didn't cross their minds. Screaming and then later half-passed out, it can be difficult for someone unfamiliar with Ellie / or your kiddo to detect the facial features associate with Ds.
C-spine precautions after a fall and atlantoaxial instability in Down syndrome:
For me this is a big one because the American Academy of Pediatrics recently updated their health care guidelines for the child with Down syndrome. In this new update, routine X-rays to screen for AAI are no longer recommended. This means that your child could be walking around with AAI and then have a serious fall. Add that to the low muscle tone and the loose ligaments and joints (see about section about why it is important to list Down syndrome in the past-medical history)and your child could have a neck injury (ie. join dislocation) to go with her head injury.
|Photo courtesy of: specialneedsjudo.eu|
This was actually the most interesting part of our EMS interaction. Apparently, when the child is very young or very little, EMS uses a car seat to help stabilize the neck [C-Spine Precautions]. The car seat is strapped to the stretcher--the stretcher's belts are threaded through the car seat the same way you would install it in a care. The neck brace is applied to the child and then the child is strapped into the car seat. Foam padding and tape are further used to stabilize the head/neck. In the picture above, Ellie is indeed sitting in her car seat. The EMS said that the added benefit to this method is that the scared child is in a familiar seat. I will be honest with you. Ellie was pretty out of it so I doubt she really cared about being in her own, familiar car seat, but I do understand what EMS was getting at!
*Disclaimer: this post does not substitute any medical information or advice provided by your child's pediatrician or other health care provider. This post is a compilation of my education and experience as a peds nurse practitioner as well as my experience as being a mother. A mother to a very active little girl who happens to have Down syndrome. All medical questions and concerns should be directed to your child's health care provider.*-- A.T.
Resources for Parents:
"Head Injury ER Patient/Caregiver Packet." Loyola University Health Services
"Head Injury and Seizures". Epilepsy Foundation.
"Keeping Your Cool When Kids Bump Heads" KidsGrowth.com
Kids Health Parent First-Aid on Falls
"Seizures". Boston Children's Hospital
The Epilepsy Foundation
"Cervical Spine; C-spine; spine precautions". London Health Sciences Centre
"Atlantoaxial Instability". eMedicine.com