INJURIES AND ACCIDENTS IN

PEDIATRICS

KAJAL

60

Injury versus Accident• Accident (WHO): an event independent of human willpower,

caused by an external force, acts rapidly and results in bodily or mental damage

• Injury: refers to the damage resulting from acute exposure to physical and chemical agents

• Accident is the event while injuries the consequences• Accidents are random, chance, uncontrollable events but

injuries are describable, epidemiologic conditions that can be controlled and prevented

Interactive Model of Injuries

VICTIM(HOST)

AGENT

HUMAN ENVIRONMENT

PHYSICAL ENVIRONMENT

Primary Factors in Pediatric Accidents

Increased vulnerability and/or risk situation

Psychosocial (endogenous)

Predisposing Factors

Environmental (exogenous)

Predisposing Factors

Accident

Precipitating Factors

Precipitating Factors

Classification of Injuries

Unintentional Injuries:

(Road traffic injuries,

Poisoning,

Falls,

Fire and burn injuries,

Drowning)

Intentional Injuries:

Mechanism of injuryMechanism of injury

• Massage in newbornsMassage in newborns

• Fall while walking/running/sports/heightFall while walking/running/sports/height

• Vehicular accident: pedestrian/ in vehicleVehicular accident: pedestrian/ in vehicle

• Crush injury: door, heavy objectCrush injury: door, heavy object

• Sharp object : impalement/ bitesSharp object : impalement/ bites

• Large object falling on child: chest / Large object falling on child: chest / abdomenabdomen

Site of InjurySite of Injury

• Head injuryHead injury

• Face , neck, mouth injuryFace , neck, mouth injury

• Chest injuryChest injury

• Abdominal injuryAbdominal injury

• Limb injuryLimb injury

Breast abscess following massageBreast abscess following massage

OVERVIEW OF COMMON ACCIDENTAL INGESTION

INGESTION INGESTION CLINICAL CLINICAL MANIFESTATIOMANIFESTATION N

NURSING NURSING TREATMENT TREATMENT

INTERVENTIONS INTERVENTIONS

Salicylate (Aspirin)Salicylate (Aspirin) TinnitusTinnitusHyperpyrexiaHyperpyrexiaSeizuresSeizuresBleedingBleedingHyperventilationHyperventilation

EmesisEmesisHydrationHydrationVitamin KVitamin K

Activated charcoalActivated charcoal

Anticipatory Anticipatory guidanceguidanceBleeding Bleeding precautionsprecautions

Counseling if suicide Counseling if suicide

attemptattempt AcetaminophenAcetaminophen(Tylenol)(Tylenol)

Liver necrosis in 2-5 Liver necrosis in 2-5 days; nausea; days; nausea; vomiting; pain in R vomiting; pain in R upper quadrant; upper quadrant; jaundice; jaundice; coagulation; coagulation; abnormalities, abnormalities, hepatoxichepatoxic

-EmesisEmesis Mucomyst Mucomyst (antidote)(antidote)

-Counseling if -Counseling if suicide attemptsuicide attempt- Liver assessment- Liver assessment

Lead (paint, also in Lead (paint, also in soil near heavily soil near heavily trafficked roadways, trafficked roadways, household dust)household dust)

-Developmental -Developmental regressionregression-Impaired growth -Impaired growth (encelophalopathy)(encelophalopathy)-Irritability-Irritability-Increased -Increased clumsinessclumsiness

-Chelation therapyChelation therapy-EDTAEDTA-BalBal-Child must be well Child must be well hydratedhydrated

-Neuro assessmentNeuro assessment-Diet high in calcium, Diet high in calcium, ironiron-Educate parents to Educate parents to wash chuld’s hands, wash chuld’s hands, toys frequently to toys frequently to remove lead dustremove lead dust-Lead abatementLead abatement

Hydrocarbons Hydrocarbons (kerosene, (kerosene, turpentine, gasoline)turpentine, gasoline)

-Burning in mouthBurning in mouth- choking and choking and gagginggagging-CNS depressionCNS depression

-DO NOT INDUCE DO NOT INDUCE EMESISEMESIS-Activated charcoalActivated charcoal-Gastric lavageGastric lavage

If vomiting, reduce If vomiting, reduce aspirationaspiration

Corrosives (drain or Corrosives (drain or oven cleanser, oven cleanser, chlorine bleach, chlorine bleach, battery acid)battery acid)

-Burning in mouth-Burning in mouth-White swollen White swollen mucous membranesmucous membranes-Violent vomitingViolent vomiting

- DO NOT INDUCE - DO NOT INDUCE EMESISEMESIS-Dilute toxin with Dilute toxin with waterwater-Activated charcoalActivated charcoal

Keep warm and Keep warm and inactiveinactive

MANAGEMENT OF INGESTION

• Ingestions– General information

• Emergency care: ABCs• Identify substance, save evidence of poison• Call poison control center for treatment advice • Removal of substance

• syrup of ipecac• Emetic• 15 cc with 200-300 cc of water• Save emesis• Contraindications

– Unconscious– Convulsing – Ingested hydrocarbon, lye, strychnine

• Activated charcoal• Gastric lavage

• Administer specific antidote• Provide supportive therapy• Educate parents about childproof environment• Provide anticipatory guidance• Infants and toddlers: at risk because everything goes

into the mouth

• Adolescents: at risk for intentional ingestion

BURNS

• 1. Characteristics of burns in children

• Due to the difference in proportions of head, trunk and limbs, burn percentages are rated differently for children

• Due to the high percentage of extracellular fluids in the child, fluid loss can quickly leas to hypovolemic shock.

• 2. Treatment• similar to adult • Children are likely to resist eating enough calories to

sustain healing and growth needs. Parenteral or enteral feedings are usually necessary.

• 3. Rehabilitation• Incorporate play into the PT and OT regimens for

improved success.• Consider psychosocial needs of the child • Adjustment and transition back to school may be very

difficult for the child who has sustained at disfiguring burn

FRACTURES

• 1. Characteristics of fractures in children• Due to immaturity of bones and incomplete ossification,

greenstick (incomplete) fractures are commonly seen• Fractures to the epiphysis (growth plate) are of greater

concern as growth in limb can be stunted depending on the amount of injury

• 2. Treatment• Similar to adult, although pediatric fractures often have

shorter healing times• May use cast (plaster or more commonly, fiberglass) soft

splint, traction or bracing

COMPLICATION OF FRACTURES IN CHILDREN

• MALALIGNEMENT

• PHYSEAL ARREST

• OVERGROWTH

• REFRACTURE CAUSED BY RAPID FRACTURE HEALING

• SHORTENING OF LIMB

• MALUNION,NONUNION FAT EMBOLISM

MUSCULOSKELETAL DISORDERS

• Scoliosis• Lateral curvature of the spine• Most common form is idiopathic seen (predominately) in

adolescent females; unknown etiology• Acquired scoliosis associated with deformity resulting

from other neuromuscular disorders• Diagnosis• 1) Classic signs: truneal asymmetry; especially noted in

hips and shoulders, posture• 2) Screening exam in school: child flexes at waist; one

scapula more prominent• 3) Spinal x-ray

• e. Treatment• 1) Mild scoliosis (20˚ curvature): observation,

encourage physical exercise • 2) Moderate scoliosis (20˚-40˚curvature):

Milwaukee brace (pelvis to neck), Boston brace (body jacket/TLSO brace)

• a) Goal is to prevent worsening of curve• b) NURSING INTERVENTIONS

– Risk for noncompliance: difficult for adolescent due to body image concerns; must wear 23 hours a day (one hour off hygiene care); wears T-shirt under brace

– Body image disturbance: Boston brace better accepted (can be completely hidden under clothing)

• 3) Severe scoliosis (40˚ curvature): surgery • a) Spinal fusion with instrumentation• b) Requires prolonged immobilization in cast,

brace or body jacket• c) NURSING INTERVENTIONS• (1) High risk for injury related to spinal

manipulation: log roll first 24 hours; neurovascular checks; advance activity as ordered; observe for paralytic ileus

• (2) Pain: adolescent good candidate for PCA pump

Children and drowning

Drowning refers to an event in which a child’s airway is submerged in liquid, leading to an impairment to breathing. The outcome can be fatal or non-fatal, with some non-fatal drowning events leading to significant neurological damage.

Places where children drown • Sea, lakes, streams • Swimmingpools • Wells, cisterns

• Buckets • Bathtubs,Gardenponds

RISK FACTORS• children under the age of five are at greatest risk of drowning,

although adolescents (15–19 years of age) also have high rates.

• Boys are almost twice as likely as girls to drown

• Drowning is strongly associated with poverty, particularly with regard to parents’ educational level, number of children in the family and ethnicity

• Populations most at risk are those living in low-income countries of densely populated communities with high exposure to open water

• Other risk factors for drowning include: lack of available and accessible safety equipment (e.g. life jacket), travel on unsafe water transport (e.g. overcrowded ferries)

MANAGEMENT• Rapidly assess airway, breathing, circulation and

conscious state.• If child is in cardiorespiratory arrest proceed immediately

with Resuscitation guidelines.• Airway and breathing (protect cervical spine if any

possibility of injury)

• If spontaneously breathing administer 100% oxygen by face mask.

• Intubate and ventilate if:– inadequate respiration– falling arterial oxygen concentration despite increased

inspired oxygen– persisting depressed conscious state.

• Perform chest X-ray.

CirculationAssess pulse rate and volume, blood pressure and capillary return.

Insert intravenous line.

Perform FBE, serum glucose, electrolytes and creatinine.

If circulation is inadequate give fluid bolus of 20 ml/kg.

Cerebral support• Avoid any further episodes of hypoxia and hypercarbia.• Optimise circulation as best possible.• Once shock is reversed fluid restrict to 75% maintenance.

• Monitoring and control of intracranial pressure is occasionally required.

Temperature• Actively rewarm children slowly to a core temperature of

34 degrees.• Passively rewarm over 34 degrees

General• Admit to appropriate inpatient unit.• Administer penicillin for respiratory prophylaxis.• Corticosteroids are not recommended.

Adverse prognostic factors• Immersion time > 10 minutes.

• Rectal temperature < 30°C.

• Absence of any initial resuscitative efforts.

• Arrival in hospital with CPR in progress or in coma.

• Requirement of cardiopulmonary resuscitation.

• Initial serum pH < 7.0

INTENTIONAL INJURIES• Homicides

• Sexual assaults

• Neglect and abandonment

• Maltreatment

• Suicides

• Collective violence (war)

PREVENTION OF INTENTIONAL INJURIES IN CHILDREN