Transcript Slide 1

Pediatric Accidents
Children are Vulnerable to Injury
• Natural curiosity
• Drive to test and master new skills
• Attempted activities before
developmental readiness
• Self-assertion and challenges to rules
• Desire for peer approval
Children are Susceptible to injury
Common Pediatric Accidents
• Head Trauma
• Drowning/Near Drowning
• Poisoning
• Burns
• Bodily Injury/Suicide
Head Trauma
• MVA most common cause
• Head injuries also caused by falls from
swings, bikes
• In a front end crash at 30 mph
unrestrained children will hit the
dashboard with the same force as the
impact received from falling 3 stories to a
solid surface.
Nursing care of the child with head trauma
Take an Accurate History
• Any loss of consciousness
• Temporary amnesia
• Lethargy
• Inability to recognize caregivers
• Nausea or vomiting since the injury
• Abnormal behavior for age
Nursing care of the child with head trauma
Assessment
• Need immediate baseline VS
• Respiratory system
• Cardiovascular system
• Neurological assessment (Glasgow
Coma Scale)
• Look for physical signs of ICP
• Assess at frequent intervals for
changes
GLASCOW COMA SCALE
Neurological Assessment on eye movement,
verbal response and motor movement
Score out of 15, usually reported as 3 scores
Best eye response (E)
4-Eyes opening spontaneously.
3-Eye opening to speech.
2-Eye opening to pain/ pressure on the patient’s
fingernail, supraorbitalor sternum
1- No eye opening.
GLASCOW COMA SCALE
Best verbal response (V)
5-Oriented.
4-Confused.
3-Inappropriate words. (Random or
exclamatory articulated speech, but no
conversational exchange).
2-Incomprehensible sounds. (Moaning but
no words.)
1- None.
Best motor response (M)
6-Obeys commands.
5-Localizes to pain. (Purposeful movements
towards changing painful stimuli)
4-Withdraws from pain (pulls part of body away
when pinched)
3-Flexion to pain (decorticate response)
2-Extension to pain (decerebrate response)
adduction, internal rotation of shoulder,
pronation of forearm).
1-No motor response.
Infant Adaptations to GCS
Eye Opening
4- Spontaneous
3- To speech
2- To pain
1- No response
Verbal Response
5- coos, babbles
4- irritable, cries
3-cries to pain
2-moans, grunts
1-no response
Motor Response
6-Spontaneous
5-localizes pain
4-withdraws from
pain
3-flexion
2-extension
1-no response
Severity of Head Injuries Based on Glasgow Coma
Scale
• Mild (Score of 13-15)
-- Possible headache and cognitive deficits
(especially affecting memory)
-- Possible stress intolerance
• Moderate (Score of 9-12)
-- Headache, memory deficits, cognitive
deficits
-- Difficulty with activities of daily living
-- Rarely but occasionally results in death
Glasgow Coma Scale (cont.)
• Severe (Score of 3-8)
-- Posttrauma syndromes and cognitive,
emotional, motor, and sensory deficits
caused by irreversible brain injury
-- Long-term care or support in the
community usually needed
-- May result in death
Increased Intracranial Pressure (ICP)
INFANT
Child
• Poor feeding or vomiting
• Headache
• Irritability or restlessness
• Diplopia
• Lethargy
• Mood swings
• Bulging fontanel
• Slurred speech
• High-pitched cry
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• Altered level of
consciousness
Increased head circumference
Separation of cranial sutures • Nausea and
vomiting,
Distended scalp veins
especially in the
Eyes deviated downward
morning
(“setting sun” sign)
• Increased or decreased
response to pain
Head Trauma Interventions
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Spinal immobilization until x-ray is back
HOB 30 degrees
Monitor for ICP
Prepare for intubation, possible respirator
Evaluate neuro and VS
Strict I & O
Medications
• Anticonvulsants: seizure prevention
• Osmotic and loop diuretics: deplete
water from intracellular and
interstitial compartments, decrease
cerebral fluid volume and ICP
• Steroids: decrease inflammation
Common Pediatric Head Injuries
Skull fracture
Linear or depressed
Intracrainal Hemorrhage
Subdural Hematoma
Epidural Hematoma
Concussion
TBI
Skull Fractures
• Linear
– Fracture of any bone that comprises
the “base” of the skull
– Leads to increased risk for infection
and CSF leak
• Depressed
– Often associated with a direct blow
from a solid object
– Fragments may require surgical
removal to protect underlying cerebral
tissue and vasculature
Signs and Symptoms of Skull Fractures
• Headache
• Decreased LOC
• Otorrhea, Rhinorrhea that tests
positive for glucose
• Unilateral hearing loss
• Orbital or postauricular ecchymosis
Diagnosis of Skull Fractures
• Confirmed by skull and spinal
x-ray
–CT, MRI if ICP is suspected
• Accurate history of injury
–Helps to determine the type of
injury and if child loss
consciousness
Treatment
Linear:
• Observation
• Analgesia
• Repeat x-ray in about 3 weeks to
confirm healing
Depressed:
• Facilitate drainage of CSF
(positioning)
• Prophylactic ABX
• Check skin integrity
• Cough suppressant
Intracrainal Hemorrhage
• Subdural Hematoma
– Collection of blood between the dura
mater and cerebrum
• Epidural Hematoma
– Collection of blood between the skull
and the dura mater
Subdural Hematoma
• Caused by trauma or violent shaking that
cause neurons bleed
• Child abuse, “shaken baby syndrome” or
birth trauma are common non-accident
causes
Signs & symptoms:
• LOC changes-Confusion, irritability, lethargy
• Ipsilateral pupil dilatation
• Seizures
• Vomiting
• Retinal hemorrhage
Epidural Hematoma
• Caused by severe blunt head
trauma that ruptures the middle
meningeal artery
Signs & Symptoms
• Delayed onset of symptoms then rapid
deterioration in status
• LOC changes- sleepy, lethargic
• Unequal fixed dilated pupils
• Contralateral paresis or paralysis
• Seizures
• Vomiting
• Headache
Diagnosis and Management for both
• Diagnosis by CT Scan
• Interventions
– Surgical removal of the accumulated
blood (Crainotomy)
– Cauterization or ligation of the torn
artery
*Early intervention is the key to
avoiding increased ICP & brain
anoxia
Concussion
• Closed head injury
• Caused by a blow to the head or a rapid
deceleration resulting in transient neuro
changes
• Signs and Symptoms
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N&V
HA
Dizziness
Brief loss of consciousness
• Concern: permanent neuro sequelae and
recognition since child may have no
memory of events
Concussion Management
• R/O skull fracture with x-ray, CT
• Observation for 24 hours to r/o trauma,
edema, laceration
• If discharged teach parents to assess for
LOC q 1-2 hours, check pulse
• If child’s behavior changes seek help
TBI –Traumatic Brain Injury
• Trauma to head causing permanent
disability
• Range on deficits
– Cognitive defects
– Emotional and behavioral problems
– Physical disability
– Self care deficits
• Long term rehabilitation is treatment
Car Safety
• Rear-facing seat from birth to 1 year and 20
lbs
• Toddlers should be restrained upright and
forward facing until 40-65 lbs (depending
on model) average 3-5 years of age or when
shoulders above harness straps
• Booster seat with lap and shoulder belt is
needed for child weighing more than 40 lb
until 4’9’’ in ht (ave 8-12 yrs) then may
switch to seat belt alone
• Children under 13 should not ride in a front
seat that is equipped with air bag
Drowning/Near Drowning
• Drowning
– Death due to suffocation from submersion in
liquid. (alveoli blocked)
– 3500 children die annually; toddlers and
preschoolers most frequent victims
• Near Drowning
– A submersion injury which requires
emergency treatment in where the child
survives the first 24 hours.
Near Drowning
Management:
• Immediate mouth to mouth resuscitation;
CPR if necessary
• Goal: to increase child’s oxygen and
carbon dioxide exchange capacity;
mechanical ventilation
• Gradual warming of body temperature
• 21% of near drowning have neurologic
damage
Poisoning
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Chemical injury to a body system
Physical emergency for child
Emotional crisis for parents
Important to calm and support parents
Explore circumstances of injury
Prevention of recurrence
Unintentional vs. intentional
Management of Poisoning
Initial Intervention:
Terminate Exposure!
• empty mouth of pills, plants
• flush eyes or skin
• remove contaminated clothes
Try to identify the poison
1. Take an accurate history
2. Physical Exam
Neuro
Resp
Cardiac
3. Obtain Labs
Intervention
While waiting decision for intervention:
• Maintain patent airway
• Maintain effective breathing pattern
• Maintain vital signs within normal range
• Maintain body temperature
Remove Poison, and Prevent Absorption
Three ways of gastric
decontamination:
Syrup of Ipecac
Gastric Lavage
Activated Charcoal
Syrup of Ipecac
• Induces emesis
– Contrindicated in some poisons
– On-going vomiting
– Electrolyte disturbances
• No longer recommended to have at
home
– It doesn't completely remove poison
– Vomiting can lead to mistrust with other
treatments
– Misuse by anorexic/bulimic adolescents
Gastric Lavage
• Used in 1st 1-2 hours after ingestion
of very toxic poison that is rapidly
absorbed
• 50-100ml of saline flushed into NG
tube, aspirated until clear
• Save first specimen for toxicology
analysis
• Disadvantages:
Activated Charcoal
• odorless, tasteless, fine, black
powder
• treatment of choice when posion is
unknown
• absorbs many compounds creating
a stable complex
• mixed with water or saline to form a
“slurry” (black mud)
Acetaminophen Poisoning
Signs & Symptoms:
• Anorexia, nausea, vomiting
• Liver tenderness
• Liver toxicity: usually occurs after
24h (blood level of drug)
• Assess liver function: elevated
SGOT, SGPT levels
Management
• Gastric Lavage if within the 1st hr of
ingestion
• Then Activated charcoal
• Mucomyst is antidote, however…
In aLL poisoning when child is stable…
Assess for contributing factors:
• Inadequate support systems
• Marital discord
• Discipline techniques (behavior
problems)
Institute anticipatory guidance: based on
child’s developmental level (child-proof
home
May require home visit
The Home Visit
• Educate re: safe storage of toxins, return immediately
after use to safe storage
• Offer strategies of effective discipline (limit setting)
• Phone number of Poison Control by phone, have
babysitters aware
For all parents-teach to
Call Poison Control Center first in event of poisoning
Information they will need to provide:
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age, weight
name of product
degree of exposure or amount swallowed
time of exposure
route of poisoning
symptoms
home management
Lead Poisoning
 Usual source: paint chips from window
sill, crib, furniture
 lead dust from home remodeling
 folk remedies
 ceramics (unglazed pottery)
 cigarette butts and ashes
 lead in soil and water from old lead pipes
Symptoms of Lead Poisoning
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Irritability
Headaches
Fatigue
Abdominal pain
Cognitive and motor delays
Often, no symptoms
Screening is essential.
Diagnosis
Venous lead level: poisoning present
when 2 successive blood levels > 10ug/dl
serum iron and serum iron binding
capacity: iron deficiency can enhance
lead absorption and toxicity
• Abdominal flat plate: may show
radiopaque foreign materials that were
ingested in the last 24-36 hours
Effects of Lead on the Body Systems
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Hematologic: anemia
Renal: kidney damage
Skeletal: lead deposits in bones
Neurologic:
• low level: hyperactivity, hearing impairment,
distractibility, mild intellectual deficits
• high level: MR, paralysis, blindness,
seizures, coma, death
Management
• lead level > 15: prevent further lead
exposure (nutritional education,
more frequent screening)
• lead level > 25: environmental
evaluation, remove child from the
environment
• lead level > 30: chelation therapy
Chelation Therapy
removes lead from soft tissue and bones
• PO chelation for levels 30-45
• IM chelation for levels above 70
– edetate calcium disodium (EDTA): deep IM
injection (very painful), toxic to kidneys
Nursing Management
• Monitor serum Ca levels, renal function
– I & O, BUN, creatinine, check protein in
urine
• Assist families with making changes to
protect the child from further exposure
• Children must be followed to evaluate
development and intelligence i.e. proper
school placement
Reducing Blood Lead Levels
• Wash & dry child’s hands & face frequently,
especially before meals
• Wash toys & pacifiers
• During remodeling keep children & pregnant
women out
• Don’t store foods in open containers, especially
imported
• Don’t use pottery for eating
• Make sure child eats regular meals, lead is
absorbed easier on an empty stomach
• Diet should contain iron and calcium
Burns
• intravascular capillaries become
very permeable
• large amounts of fluids, proteins, &
electrolytes shift to the interstitial
space
• results in edema of the burned area
and a loss of circulatory volume
Other Effects
• Heat loss: (larger body surface
area in relation to body weight)
• Infection (tissue necrosis)
• Inhalation injuries: (progressive
edema; airway obstruction)
Nursing Role
History:
• When, where, how injury occurred
• Type of burn
• Past medical history
• Treatment prior to arrival in ED
Signs and Symptoms:
• vary & are related to the depth of injury,
affected surface area, and presence of
inhalation injury
Five Methods of Burn Injuries
• Inhalation: symptoms may not be seen
for 24 hours after exposure
• Thermal: dermal exposure to heat and/or
flame
• Electrical: contact with electric current
• Chemical: dermal exposure to corrosives
• Radiation: radiation therapy
Depth of injury
1st degree/(superficial
partial thickness)
• epidermis; erythema,
pain, appears dry
2nd degree/(deep partial
thickness)
•entire epidermis & dermis;
moist, blisters, erythema,
pain
3rd degree/(full thickness)
•epidermis & dermis,
adipose tissue, fascia,
muscle & bone; dry,
leathery appearance, range
in color (white to brown or
black), no sensation to pain
Body Surface Area
• use age appropriate charts to determine
the extent of the burn
• or by using the size of the child’s
palm(approximately 1% of the tbsa)
– add the number of times the child’s palm
would fit into the affected area will provide
an estimation of the extent of the burn
surface area
Location of Burns determines
intervention
•Face and neck
•Hands and feet
•Perineum
Intervention
• Stop the burning process
• Ensure a patent airway
• Deliver oxygen/assisted
ventilation
• Obtain two vascular access with
large bore catheter
IV Fluids
• Warmed crystalloid solution (RL)
• 2-4ml x weight in kg x BSA = total
amount of fluids to be infused during the
first 24h
• Of this amount ½ should be given in the
first 8 hours
• remainder should be given equally over
the next 16 hours.
• Calculation of the 24 hours begins from
the time of the actual burn injury
Objectives of IVF
• Compensate for water and sodium
loss
• Restore circulatory volume
• Provide profusion
• Improve renal function
Therapy
• Open tx
• Closed tx
• Silvadene cream: drug of
choice
• Escharotomy
• Debridement
• Grafting
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Whirlpool therapy
Analgesia
Strict I+O
Isolation
When stable
• Nutrition
Suicide
Third leading cause of death
during the teenage years.
Motives
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Desire to influence others
Gain attention
Communicate love or anger
Escape a difficult situation
Risk Factors for Suicide
• Suicidal clues
-- Cryptic verbal messages
-- Giving away personal items
-- Changes in expected patterns of
behavior
• Specific statements about suicide
• Preoccupation with death, interest in
death themes in literature and art
• Frequent risk-taking or self-abusive
behavior
• Use of alcohol or drugs to cope
Risk Factors for Suicide
• Overwhelming sense of guilt or shame
• Obsessional self-doubt
• Signs of mental illness such as delusions
or hallucinations
• Significant change/major life event that is
internally disruptive
• History of physical or sexual abuse
• Homosexuality, especially if teen discovers
gender orientation early in adolescence, or
experiences violence or rejection because
of sexual orientation
Early detection is key to prevention
Threats of Suicide
• A suicide gesture or threat should
never be ignored
• The child should be encouraged to
discuss the thought
• The nurse should try to determine
whether the child has a plan and
whether the plan is lethal
• A qualified health care professional
should provide help
Nursing Considerations
A history of a previous suicide attempt is a
serious indicator for possible suicide
completion in the future
Discuss with the parents of at-risk
teenagers to remove firearms, weapons,
alcohol, medications from the home
Nursing Considerations
• Those that express a specific plan should
be monitored at all times – communicate
in an empathetic & non-judgmental way
to decrease sense of isolation & rejection
• Be physically & emotionally present
offering opportunities to discuss feelings
• Discuss alternative coping mechanisms
CASE STUDY
• A preschool teacher has asked the nurse
to develop and present a program on
safety for toddlers for interested parents.
• Devise a topical outline for this program.
• Under each topic, list at least three
specific suggestions to offer parents.
Motor Vehicle Accidents
1._________________________________
_______________________________
2._________________________________
_______________________________
3._________________________________
_______________________________
Drowning
1._________________________________
_______________________________
2._________________________________
_______________________________
3._________________________________
_______________________________
Burns
1._____________________________________
___________________________
2._____________________________________
___________________________
3._____________________________________
___________________________
Poisoning
1.____________________________________________
____________________
2.____________________________________________
____________________
3.____________________________________________
____________________
Falls
1._____________________________________
___________________________
2._____________________________________
___________________________
3._____________________________________
___________________________
Choking
1._________________________________
_______________________________
2._________________________________
_______________________________
3._________________________________
_______________________________
Bodily Injury
1._________________________________
_______________________________
2._________________________________
_______________________________
3._________________________________
_______________________________
A 2-year-old child is admitted to the
neurosurgical unit following a head
injury. The nurse is using the Glasgow
Coma Scale to measure neurological
function. Which of the following
assessment findings indicate the lowest
level of functioning for this child?
a.
b.
c.
d.
Confusion
Irritable and cries
Eyes open to pain only
No response to painful stimuli
When caring for a child with lead
poisoning, the primary goal is to:
a. Assess for pica
b. Promote excretion of lead via
chelating agents
c. Correct the anemia
d. Reverse the neurological effect
If observed in a home with a 2year-old child, which action
would the nurse identify as an
INEFFECTIVE safety measure?
a. Keeping the poison control
number by the phone
b. Installing safety latches on
bathroom cabinets used for
medication
c. Keeping poisonous items in a
locked cabinet
d. Keeping al substances in their
original containers
A 10-year-old boy receives a blow to his head
with a hard baseball and is admitted to the
hospital for observation. If the child were
to develop an subdural hematoma, he
would most likely display symptoms:
a. In the ER or soon after arriving on the unit
b. On the unit over the next few days
c. After discharge home
d. Over the next two months
In which type of poisonings should the
nurse question orders to induce
vomiting?
a. Aspirin
b. Acetaminophen
c. Iron tablets
d. Drain cleaner
The nurse is providing discharge
instructions for a child who has suffered
a head injury within the last four hours.
The nurse determines there is a need
for additional teaching when the mother
states:
a.. I will call my doctor immediately if the
child starts vomiting
b. I won’t give my child anything stronger
than Tylenol for a headache
c. My child should sleep for at least 8
hours without arousing him after we get
home
d. I recognize that continued amnesia
about the injury is not uncommon
When performing a health screening on an
adolescent in the health clinic, the nurse
determines the adolescent is at a higher
risk of suicide than other adolescents of
the same age based on the following
disclosure. The adolescent states that he:
a.
b.
c.
d.
Sleeps late on the weekends
Only has a small group of close friends
Is homosexual
Often skips meals and does not worry
about nutrition