Report by Sue Corkill, HW Tolerance

Head Injuries

Head injuries are certainly one of the more popular ways to hurt characters in fanfic. The convenient thing about head injuries is that they can run the range from mild to severe and complete recovery to death with very little difficulty. This flexibility allows for great latitude in either allowing a character to recover or letting the injury lead to death.

Types of Head Injuries

Skull Fractures:
When a skull bone is broken, it's called a skull fracture. A fracture can be merely depressed, meaning it just mildly presses on the brain or it can penetrate the lining of the brain (the meninges). If this happens, then arterial or venous bleeding can occur, or cerebrospinal fluid can leak out through the nose or ear(s). Sometimes bacteria can enter through a fracture, resulting in infection. Most skull fractures don't require surgery unless the broken fragments are pressing on the brain or too far out of alignment.

Concussion:
A concussion is a brief loss of consciousness (and sometimes memory) after an injury that doesn't cause any obvious physical damage. There is no structural damage to the brain, but there is a malfunction of the brain caused by the jarring of the soft brain within the hard confines of the skull. Recovery usually occurs within a range of hours to days. Symptoms of a concussion are headache, confusion, and sleepiness.

Post-concussion syndrome is when people develop symptoms lasting longer than a few days, sometimes up to several weeks. The individual may develop dizziness, have difficulty concentrating, forgetfulness, depression, lack of feeling or emotion, and anxiety. They may also have trouble working, socializing or studying.

Most concussions don't require treatment-once they've been properly evaluated (with Magnetic Resonance Imaging {MRI} or Computerized Axial Tomography {CT Scan}). Patients (and families) are instructed to watch for symptoms of worsening brain function--worsening headaches, confusion, and increasing sleepiness.

Cerebral contusions and lacerations:
A contusion is a bruise on the brain, usually caused by a strong, direct blow to the head. Lacerations are torn brain tissue, usually caused by a skull fracture or a visible head wound. Obviously more serious than a concussion, these injuries are often diagnosed by MRI. Injury can be mild to severe, depending on the degree of tissue damage.

Intracranial hematomas:
Hematomas are collections blood, either in the brain or between the brain and the skull. Severe injury or stroke can cause them. Injury related hematomas will be either classified as subdural or epidural, which indicates location either above (epi) or below (sub) the dura mater, which is the covering of the brain tissue. MRI or CT scan is used to diagnose both injuries. Epidural hematomas generally occur more rapidly than subdural ones, as epidural hematomas are from arterial injury while subdural are from venous bleeding. Epidural hematomas present rapidly (usually a matter of minutes to maybe one or two hours). Surgery is required to stop the bleeding. Recovery depends on the area of brain affected by the injury and can be full or partial.

Subdural hematomas allow a little more time before requiring intervention, maybe even up to twenty-four hours, depending on location and how fast the venous blood loss occurs. Again, surgery will be required to remove the hematoma and control the bleeding. Symptoms include persistent headache, drowsiness, confusion, memory changes, and mild paralysis on the opposite side of the body of the hematoma.

Blown or Dilated Pupil(s):
What is a 'blown' pupil (i.e. one pupil dilated and the other reacting to light)? A dilated pupil that doesn't react to light results from swelling in the brain (from trauma-usually bleeding) that presses on the Third Cranial (oculomotor) nerve. Two dilated pupils is not good, this generally indicates profound swelling of the entire brain and just not swelling or pressure from one area on the nerve.

Post-Injury Disorders:
Head injuries can produce some disorders that show up days to years after the initial injury. These include post-traumatic epilepsy (seizures), aphasia (loss of the ability to use language) and amnesia (the total or partial inability to recall recent and/or past events).

Comments:
As for giving your fanfic character a head injury, too severe of an injury will either kill him or her or result in long term functional problems (unless that's your goal). Milder injuries can bring about just as much angst without the threat of permanent brain damage. As with any serious injury, know whether surgery is the only option for cure/recovery and plan the story's timeline and access to medical care appropriately. A character with an epidural hematoma won't survive a twenty-four hour wait for surgical intervention while a character with a mild to moderate concussion-more than likely-won't require much in the way of treatment.

Reference:
The Merck Manual-Home Edition; Chapter 75, Head Injuries;
And SJHW Tolerance's twenty-six years of experience as a nurse.