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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 • • • • • 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 • • • • • • 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 – – – – 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 • • • • • • • 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: • • • • • • • age, weight name of product degree of exposure or amount swallowed time of exposure route of poisoning symptoms home management Lead Poisoning X Usual source: paint chips from window sill, crib, furniture X lead dust from home remodeling X folk remedies X ceramics (unglazed pottery) X cigarette butts and ashes X lead in soil and water from old lead pipes Symptoms of Lead Poisoning • • • • • • 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 • • • • 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 • • • • 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 • 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