Transcript Pediatric Accidents

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
Common Pediatric Accidents
• Head Trauma
• Drowning/Near Drowning
• Poisoning
• Burns
• Bodily Injury/Suicide
HEAD TRAUMA
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, especially
Distended scalp veins
in the morning
Eyes deviated downward
(“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
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
• Can have a 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
PREVENTION
CAR SAFETY!
Car Safety: Infants
• Rear-facing seat from birth to 1 year
and 20 lbs in a Five Point Harness
Car Safety: Toddlers
• 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
– Five Point Harness
Car Safety: Preschoolers and Older
• 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
How Does the Public Know if They
Properly Installed their Child in a
Car Seat?
DROWNING/NEAR DROWNING
• Drowning
– Death within 24 hours due to suffocation
from submersion in liquid. (alveoli blocked)
– 3500 children die annually; toddlers and
preschoolers most frequent victims
• Near Drowning/Hypoxic Injury
– A submersion injury which requires
emergency treatment in where the child
survives the first 24 hours.
Hypoxic Injury
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Fluid is swallowed (aspiration)
Causes Layrngospasm
Leads to hypoxia
Child becomes unconscious
Laryngospasm relaxes
Gag reflex is lost
Swallows more water
Hypothermia as body cools
Near Drowning-Hypoxic Brain Injury
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
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 AST,
ALT
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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Often, no symptoms
Irritability
Headaches
Fatigue
Abdominal pain
Cognitive and motor delays
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: Cognitive Impairment, 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 30-69
• 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
BURN INJURY
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
• This is called “third spacing”
Other Effects
• Heat loss: (larger body surface
area in relation to body weight)
• Infection (tissue necrosis)
• Inhalation injuries: (progressive
edema; airway obstruction)
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
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
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- Parkland Formula
• 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
Example:
Child weight 70 lbs
Burned TBSA 20%
MD orders: Administer 1300ml of RL in
24 hours
Time of injury 0800 am
Time of MD order 1100 am
Drop factor 15 gtt/ml
Is this order safe?
How should this be administered?
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
• 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
Risk Factors For Suicide
• Frequent risk-taking or self-abusive
behavior
• Use of alcohol or drugs to cope
• Overwhelming sense of guilt or shame
• Obsessional self-doubt
• Signs of mental illness such as
delusions or hallucinations
Risk Factors for Suicide
• 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
• Nurse must 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
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
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3.
Drowning
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2.
3.
Burns
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3.
Poisoning
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Falls
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Choking
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Bodily Injury
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2.
3.
Practice Questions!
When caring for a child diagnosed
with severe 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 all substances in their
original containers
A 10-year-old boy is struck on his head
with a hard baseball and was taken to the
ER. If the child were to develop an
subdural hematoma, he would most likely
display symptoms:
a.
b.
c.
d.
Upon arriving to the ER
In the PICU later that day
After discharge home
Over the next two months
In which type of poisonings should
the nurse question orders to induce
vomiting?
a.
b.
c.
d.
Aspirin
Acetaminophen
Iron tablets
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 8-12
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 attracted to same sex indivudals
Often skips meals and does not worry
about nutrition
• The community health nurse is planning
a program to prevent MVA in toddlers.
Parents attending the program have
indicated their children weigh between
20-40 lbs. Which care safety seat should
the nurse bring to demonstrate proper
instruction?
1. Rear facing 5-point harness
2. Forward facing 5 point-harness
3. Booster seat with lap and shoulder belt
4. No seat as seat belt alone in back seat is ok
Fill in the Blank
• The nurse is assessing a child who was
unrestrained in a car and sustained a
crash. The child was transported to the
ER and is presently in the positioning
below:
The nurse records this as a _____ on the
motor response section of the GSC