Transcript Severe Head Injury

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
Head Trauma

MVA most common cause
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Head injuries also caused by falls from swings,
bikes
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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
 eye movement
 verbal response
 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
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)
1-No motor response
Decorticate posturing
Decerebrate posturing
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

Mild Head Injury (Score of 13-15)
• Possible headache and cognitive deficits (especially
affecting memory)
• Possible stress intolerance

Moderate Head Injury (Score of 9-12)
◦ Headache, memory deficits, cognitive deficits
◦ Difficulty with activities of daily living
◦ Rarely but occasionally results in death
Severity of Head Injuries

Severe Head Injury (Score of 3-8)
◦ 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
 Poor feeding or vomiting
 Irritability or restlessness
 Lethargy
 Bulging fontanel
 High-pitched cry
 Increased head circumference
 Separation of cranial sutures
 Distended scalp veins
 Eyes deviated downward
(“setting sun” sign)
 Increased or decreased
response to pain
Child
• Headache
• Diplopia
• Mood swings
• Slurred speech
• Altered level of
consciousness
• Nausea and vomiting,
especially in the
morning
Head Trauma Interventions
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
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Depressed
◦ Fracture of any bone that comprises the
“base” of the skull
◦ Leads to increased risk for infection and
CSF leak
◦ 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
 Unilateral
hearing loss
 Orbital or postauricular ecchymosis
Diagnosis of Skull Fractures
 Accurate
history of injury
◦ Helps to determine the type of
injury and if child loss
consciousness
 Confirmed
by skull and spinal x-ray
◦ CT, MRI if ICP is suspected
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
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
Signs & symptoms

Confusion, irritability, lethargy

Pupil dilatation

Seizures

Vomiting

Retinal hemorrhage
Epidural Hematoma
Signs & Symptoms

Can have a delayed onset of symptoms then rapid
deterioration in LOC

Unequal dilated pupils

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
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Signs and Symptoms
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N &V
HA
Dizziness
Brief loss of consciousness

Child may have no memory of events
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Can cause permanent neurological
damage
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

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Cognitive defects
Emotional and behavioral problems
Physical disability
Self care deficits
Long term rehabilitation is treatment
NYS Occupant Restraint Law

Restraints depend on height and weight of child

Drivers who operate a vehicle with an
unrestrained or improperly restrained child
under age 16 can be fined, receive license
penalty and possible criminal charges

Excludes taxi, bus, emergency vehicles

School district determines school bus rules
Children birth to 3 years
Secured in a federally-approved child
safety seat
 Seat is attached to vehicle by seatbelt or
LATCH (universal anchorage)
 Child safety seat used five-point harness
 Weight of child appropriate for seat
according to manufacture guidelines

Infants

Rear-facing seat from birth to 1 year
and 20 lbs
Toddlers

Toddlers should be
restrained upright and
forward facing until 4065 lbs (depending on
model)
Properly Restrained Toddler
High Chest Strap
Snug Straps
Children age 4 to 7

Booster seat with lap and shoulder belt is
needed for child weighing more than 40 lb
No Booster Seat- Risk for Cervical
Injury
Properly Restrained Child in
Booster
Strap is across
chest not neck
Children age 8 and older
Once a child is 4’9’’ in ht and greater than
100 lb then may switch to seat belt alone
that has a lap and shoulder harness
 Shoulder belt should not touch throat

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Children under 13 should not ride in a
front seat that is equipped with air bag
DROWNING
AND
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
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
Foreign Body Ingestion

Small children explore their worlds by
putting things in their mouths

Objects (usually food or a toy) can be
lodged in the trachea and obstruct
breathing

Children under age 4 greatest risk
Prevention of Choking

Avoid hard foods
◦ hard candy, nuts, popcorn, raw
fruits and vegetables, seeds

Avoid soft foods
◦ hot dogs, grapes, cheese cubes,
caramel , chewing gum
Prevention of Choking
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Supervise child when eating
Do not give children food in car
Never let children run or play with
lollipops in mouth
Check floors, rugs for hazards (coins,
office supplies, broken crayons, jewelry)
Keep latex balloons out of reach
Keep small objects away from reach
POISONING
Poisoning
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
Take an accurate history

Physical Exam

◦ Resp
◦ Cardiac
◦ Neuro
◦
Obtain Labs
While waiting decision for
intervention
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Maintain patent airway

Maintain effective breathing pattern
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Maintain vital signs within normal range
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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
 used
powder
if poisoning is >2 hrs
 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
Acetaminophin Poisoning

Management
◦ Gastric Lavage if within the 1st hr of ingestion
◦ Then Activated charcoal
◦ Mucomyst is antidote, however…
In All types of 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 (locked not latched),
return immediately after use to safe storage
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Offer strategies of effective discipline (limit setting)
Phone number of Poison Control by phone, have
babysitters aware
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
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
 Often, no
symptoms
 Irritability
 Headaches
 Fatigue
 Abdominal
pain
 Cognitive and motor delays
Screening is essential
Lead Poisoning Can Cause
Anemia
 Kidney damage
 Neurologic changes

• low lead level: hyperactivity, hearing
impairment, distractibility, mild intellectual
deficits
• High lead level: cognitive impairment,
paralysis, blindness, seizures, coma, death
Management
 Mild lead level
◦ prevent further lead exposure
◦ nutritional education
◦ more frequent screening
 Moderate lead level
◦ environmental evaluation
◦ remove child from the environment
◦ chelation therapy
Chelation Therapy

removes lead from soft tissue and bones

PO chelation for moderate to high levels

IM chelation for severely high levels
◦ edetate calcium disodium (EDTA): deep IM
injection (very painful), toxic to kidneys
Nursing Management

Assist families with making changes to
protect the child from further exposure
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Children must be followed to evaluate
development and intelligence i.e. proper
school placement
Reducing Blood Lead
Levels
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Wash & dry child’s hands & face frequently,
especially before meals
Wash toys & pacifiers
During remodeling keep children out of house
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
BURN INJURY
Five Methods of Burn Injuries
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Thermal
◦ dermal exposure to heat and/or flame
Electrical
◦ contact with electric current
Chemical
◦ dermal exposure to corrosives
Inhalation
◦ symptoms may not be seen for 24 hours after
exposure
Radiation
◦ exposure to radiation therapy
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 leads to 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
Depth of injury
1st degree (superficial partial thickness)
 Burn affects epidermis
Burned area has erythema, pain, appears dry
2nd degree (deep partial thickness)
Burn affects entire epidermis & dermis
Burned area is moist, blisters, erythema, pain
3rd degree (full thickness)
Burn affects epidermis & dermis, adipose tissue, fascia,
muscle & bone
Burned area is dry, leathery appearance, range in color
(white to brown or black)
No sensation to pain in burned area
Body Surface Area

Use age appropriate charts to determine the
extent of the burn
Intervention
 Stop
the burning process
 Ensure a patent airway
 Deliver oxygen/assisted ventilation
Interventions
Obtain two vascular access with large
bore catheter
 Initiate IVF to
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◦
◦
◦
Compensate for water and sodium loss
Restore circulatory volume
Provide profusion
Improve renal function
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?
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
Suicidal clues

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

Significant change/major life event that is
internally disruptive

History of physical or sexual abuse

Signs of mental illness such as delusions or
hallucinations
Threats of Suicide

A suicide gesture or threat should never
be ignored

Nurse’s legal responsibility is 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
Practice Questions!
When caring for a child diagnosed with
severe lead poisoning, the primary goal
is to:
a.
b.
c.
d.
Assess for pica
Promote excretion of lead
Correct the anemia
Reverse the neurological effect
The nurse observes the following safety measures
for a toddler. Which of the following is ineffective?
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
The nurse is providing discharge instructions for a child
who is being discharged after 24 hours from a
concussion. 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
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 car
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