PEDIATRIC ACCIDENTSPEDIATRIC ACCIDENTS IngestionsIngestions

General informationGeneral information Emergency care: ABCsEmergency care: ABCs Identify substance, save evidence of poisonIdentify substance, save evidence of poison Call poison control center for treatment advice Call poison control center for treatment advice Removal of substanceRemoval of substance

syrup of ipecacsyrup of ipecac EmeticEmetic 15 cc with 200-300 cc of water15 cc with 200-300 cc of water Save emesisSave emesis ContraindicationsContraindications

UnconsciousUnconscious Convulsing Convulsing Ingested hydrocarbon, lye, strychnineIngested hydrocarbon, lye, strychnine

Activated charcoalActivated charcoal Gastric lavageGastric lavage Administer specific antidoteAdminister specific antidote Provide supportive therapyProvide supportive therapy Educate parents about childproof Educate parents about childproof

environmentenvironment Provide anticipatory guidanceProvide anticipatory guidance Infants and toddlers: at risk because Infants and toddlers: at risk because

everything goes into the moutheverything goes into the mouth Adolescents: at risk for intentional ingestion Adolescents: at risk for intentional ingestion

OVERVIEW OF COMMON OVERVIEW OF COMMON ACCIDENTAL INGESTIONACCIDENTAL INGESTION

INGESTION INGESTION CLINICAL CLINICAL MANIFESTATIMANIFESTATION ON

NURSING NURSING TREATMENT TREATMENT

INTERVENTIONS INTERVENTIONS

Salicylate Salicylate

(Aspirin)(Aspirin) TinnitusTinnitus

HyperpyrexiaHyperpyrexia

SeizuresSeizures

BleedingBleeding

HyperventilationHyperventilation

EmesisEmesis

HydrationHydration

Vitamin KVitamin K

Activated Activated

charcoalcharcoal

Anticipatory Anticipatory guidanceguidance

Bleeding Bleeding precautionsprecautions

Counseling if Counseling if

suicide attemptsuicide attempt AcetaminophenAcetaminophen

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

-EmesisEmesis

Mucomyst Mucomyst (antidote)(antidote)

-Counseling if -Counseling if suicide attemptsuicide attempt

- Liver - Liver assessmentassessment

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

-Developmental -Developmental regressionregression

-Impaired growth -Impaired growth (encelophalopath(encelophalopathy)y)

-Irritability-Irritability

-Increased -Increased clumsinessclumsiness

-Chelation therapyChelation therapy-EDTAEDTA-BalBal-Child must be Child must be well hydratedwell hydrated

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

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

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

-DO NOT INDUCE DO NOT INDUCE EMESISEMESIS-Activated Activated charcoalcharcoal-Gastric lavageGastric lavage

If vomiting, If vomiting, reduce aspirationreduce aspiration

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

-Burning in mouth-Burning in mouth-White swollen White swollen mucous mucous membranesmembranes-Violent vomitingViolent vomiting

- DO NOT INDUCE - DO NOT INDUCE EMESISEMESIS-Dilute toxin with Dilute toxin with waterwater-Activated Activated charcoalcharcoal

Keep warm and Keep warm and inactiveinactive

BURNSBURNS

1. Characteristics of burns in children1. Characteristics of burns in childrenDue to the difference in proportions Due to the difference in proportions

of head, trunk and limbs, burn of head, trunk and limbs, burn percentages are rated differently for percentages are rated differently for childrenchildren

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

2. Treatment2. Treatment similar to adult similar to adult Children are likely to resist eating enough Children are likely to resist eating enough

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

3. Rehabilitation3. Rehabilitation Incorporate play into the PT and OT Incorporate play into the PT and OT

regimens for improved success.regimens for improved success. Consider psychosocial needs of the child Consider psychosocial needs of the child Adjustment and transition back to school Adjustment and transition back to school

may be very difficult for the child who has may be very difficult for the child who has sustained at disfiguring burnsustained at disfiguring burn

FRACTURESFRACTURES

1. Characteristics of fractures in children1. Characteristics of fractures in children Due to immaturity of bones and incomplete Due to immaturity of bones and incomplete

ossification, greenstick (incomplete) fractures are ossification, greenstick (incomplete) fractures are commonly seencommonly seen

Fractures to the epiphysis (growth plate) are of Fractures to the epiphysis (growth plate) are of greater concern as growth in limb can be stunted greater concern as growth in limb can be stunted depending on the amount of injurydepending on the amount of injury

2. Treatment2. Treatment Similar to adult, although pediatric fractures often Similar to adult, although pediatric fractures often

have shorter healing timeshave shorter healing times May use cast (plaster or more commonly, May use cast (plaster or more commonly,

fiberglass) soft splint, traction or bracingfiberglass) soft splint, traction or bracing

MUSCULOSKELETAL MUSCULOSKELETAL DISORDERSDISORDERS

ScoliosisScoliosis Lateral curvature of the spineLateral curvature of the spine Most common form is idiopathic seen Most common form is idiopathic seen

(predominately) in adolescent females; unknown (predominately) in adolescent females; unknown etiologyetiology

Acquired scoliosis associated with deformity Acquired scoliosis associated with deformity resulting from other neuromuscular disordersresulting from other neuromuscular disorders

DiagnosisDiagnosis 1) Classic signs: truneal asymmetry; especially 1) Classic signs: truneal asymmetry; especially

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

one scapula more prominentone scapula more prominent 3) Spinal x-ray3) Spinal x-ray

e. Treatmente. Treatment 1) Mild scoliosis (20˚ curvature): 1) Mild scoliosis (20˚ curvature):

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

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

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

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

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

3) Severe scoliosis (40˚ curvature): surgery 3) Severe scoliosis (40˚ curvature): surgery a) Spinal fusion with instrumentationa) Spinal fusion with instrumentation b) Requires prolonged immobilization b) Requires prolonged immobilization

in cast, brace or body jacketin cast, brace or body jacket c) NURSING INTERVENTIONSc) NURSING INTERVENTIONS (1) High risk for injury related to spinal (1) High risk for injury related to spinal

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

(2) Pain: adolescent good candidate for PCA (2) Pain: adolescent good candidate for PCA pumppump

ONCOLOGY DISORDERONCOLOGY DISORDER

A. LeukemiaA. LeukemiaMost common childhood cancerMost common childhood cancerPeak incidence: 3-5 years of agePeak incidence: 3-5 years of ageEtiology: unknown, may be related to Etiology: unknown, may be related to

environmental exposures environmental exposures (example:radiation)(example:radiation)

Characterized by proliferation of Characterized by proliferation of abnormal white blood cellsabnormal white blood cells

Clinical ManifestationClinical ManifestationFever and infection from decreased Fever and infection from decreased

(normal) WBCs(normal) WBCsAnemia, pallor and fatigue from Anemia, pallor and fatigue from

decreased RBCsdecreased RBCsPetechiae and epistaxis from decreased Petechiae and epistaxis from decreased

plateletsplateletsLimb and joint painLimb and joint painLymphadenopathyLymphadenopathyCentral Nervous System (CNS) Central Nervous System (CNS)

involvementinvolvementHepatosplenomegaly/bleeding tendenciesHepatosplenomegaly/bleeding tendencies

Treatments: Treatments: TerminologyTerminology

Induction, remissionInduction, remission CNS prophylaxis, consolidationCNS prophylaxis, consolidation MaintenanceMaintenance

ChemotherapyChemotherapy Purine antagonists: 6-mercaptopurine (Purinethol) Purine antagonists: 6-mercaptopurine (Purinethol)

(may affect kidneys)(may affect kidneys) Alkylating agents: cyclophosphamide (Cytoxan) Alkylating agents: cyclophosphamide (Cytoxan)

(causes chemical cystitis)(causes chemical cystitis) Folic acid antagonists: methotrexate (Folex)Folic acid antagonists: methotrexate (Folex) Plan alkaloid: vincristine sulfate (Oncovine) (neuro Plan alkaloid: vincristine sulfate (Oncovine) (neuro

toxic)toxic) Steroids: prednisone (Prelone)Steroids: prednisone (Prelone) Enzymes: L-asparaginase (Elspar)Enzymes: L-asparaginase (Elspar)

NEPHROBLASTOMA (Wilms NEPHROBLASTOMA (Wilms Tumor)Tumor)

Most frequent type of renal cancerMost frequent type of renal cancer Peak age is 3 yearsPeak age is 3 years Most common clinical sign: swelling, mass Most common clinical sign: swelling, mass

within the abdomen, within the abdomen, May also see: anemia, hypertension, May also see: anemia, hypertension,

hematuriahematuria Clinical ManifestationsClinical Manifestations

Arises from embryonal tissueArises from embryonal tissueEncapsulated (do not biopsy, will “seed” tumor Encapsulated (do not biopsy, will “seed” tumor

further)further)

DiagnosisDiagnosis Intravenous pyelogramIntravenous pyelogramComputerized tomographyComputerized tomographyBone marrow to rule out metastasisBone marrow to rule out metastasisTreatmentTreatmentNephrectomy and adrenalectomyNephrectomy and adrenalectomyRadiation and chemotherapy Radiation and chemotherapy

determined by stagingdetermined by staging

Nursing ManagementNursing ManagementPreoperative carePreoperative care

Treatment begun quickly; support Treatment begun quickly; support parents and keep explanations simpleparents and keep explanations simple

Monitor blood pressure due to excess Monitor blood pressure due to excess rennin productionrennin production

Prevent rupture of encapsulated tumorPrevent rupture of encapsulated tumorpost sign on bed: “DO NOT PALPATE post sign on bed: “DO NOT PALPATE

ABDOMEN”ABDOMEN”Bathe and handle gentlyBathe and handle gently

Postoperative carePostoperative care problems related to radiation, problems related to radiation,

chemotherapy chemotherapy large surgical incisionlarge surgical incision

Pain managementPain management Gentle handlingGentle handling Prepare parentsPrepare parents

Protect remaining kidneyProtect remaining kidney Monitor blood pressureMonitor blood pressure Dipstick urine for proteine or bloodDipstick urine for proteine or blood

NEUROBLASTOMANEUROBLASTOMA

Most frequent seen below 2 years of ageMost frequent seen below 2 years of age Frequently called “silent” tumor because Frequently called “silent” tumor because

by the time of diagnosis, metastasis has by the time of diagnosis, metastasis has occurredoccurred

Clinical signs include: abdominal mass, Clinical signs include: abdominal mass, urinary retention and frequency, urinary retention and frequency, lymphadenopathy, generalized weakness, lymphadenopathy, generalized weakness, malaisemalaise

Primary site is abdomen, most often in Primary site is abdomen, most often in flank areaflank area

DiagnosisDiagnosis Computerized tomographyComputerized tomography Bone marrow to determine metastasisBone marrow to determine metastasis Excessive catecholamine production Excessive catecholamine production TreatmentTreatment Surgery to remove as much of the tunor as Surgery to remove as much of the tunor as

possible, determine stagingpossible, determine staging Chemotherapy and radiation determined Chemotherapy and radiation determined

by staging of tumorby staging of tumor

HODKIN’S LYMPHOMAHODKIN’S LYMPHOMA

Primarily affects adolescents and young Primarily affects adolescents and young adults adults

Clinical signs include: painless enlargement Clinical signs include: painless enlargement of lymph nodes (cervical most common), of lymph nodes (cervical most common), metastasis related manifestations metastasis related manifestations (persistent cough, abdominal pain), systemic (persistent cough, abdominal pain), systemic problems (pruritus, night sweats, fever)problems (pruritus, night sweats, fever)

Clinical ManifestationsClinical Manifestations Malignancy originates in lymphoid systemMalignancy originates in lymphoid system Metastasis may include spleen, liver, bone Metastasis may include spleen, liver, bone

marrow, lungsmarrow, lungs

DiagnosisDiagnosisComputerized axial tomographyComputerized axial tomographyLymph node biopsy, exploratory Lymph node biopsy, exploratory

laparotomy (to stage)laparotomy (to stage)TreatmentTreatmentRadiation and chemotherapy Radiation and chemotherapy

determined by clinical stagingdetermined by clinical stagingSurgical laparatomySurgical laparatomySplenectomySplenectomy

RENAL DISORDERSRENAL DISORDERSNEPHROTIC NEPHROTIC SYNDROMESYNDROME

ACUTE ACUTE GLOMERULONEPHRITIGLOMERULONEPHRITISS

Other namesOther names Childhood nephrosisChildhood nephrosis Post-streptococcal Post-streptococcal glomerulonephritisglomerulonephritis

EtiologyEtiology Cause unknown; may Cause unknown; may follow the toxic effects of follow the toxic effects of mercury or Tridione mercury or Tridione exposure or bee stingexposure or bee sting

Antigen- antibody Antigen- antibody reaction secondary to reaction secondary to infection elsewhere in infection elsewhere in the body, usually a the body, usually a Group A beta hemolytic Group A beta hemolytic streptococcal infection streptococcal infection of the upper respiratory of the upper respiratory tracttract

IncidenceIncidence Average age of onset Average age of onset about 2-1/2 years most about 2-1/2 years most common in boyscommon in boys

2/3 of cases in children 2/3 of cases in children under 4-7 years; more under 4-7 years; more common in boyscommon in boys

PathologyPathology Increased permeability Increased permeability of the glomerular of the glomerular membrane to proteinmembrane to protein

Inflammation of the Inflammation of the kidneys; damage to the kidneys; damage to the glomeruli allows glomeruli allows excretion of red blood excretion of red blood cellscells

Clinical manifestationsClinical manifestations Edema appears Edema appears insidiously; usually first insidiously; usually first noticed about the eyes noticed about the eyes and can advance to the and can advance to the legs, arms, back, legs, arms, back, pentoneal cavity and pentoneal cavity and scrotum; massive scrotum; massive protenuria, anorexia; protenuria, anorexia; pallorpallor

Periorbital edema Periorbital edema appears insidiously; tea-appears insidiously; tea-colored urine from colored urine from hematuria, hypertension hematuria, hypertension oliguriaoliguria

Blood pressureBlood pressure Usually normal, transient Usually normal, transient elevation may occur elevation may occur earlyearly

Varying degrees of HPN Varying degrees of HPN maybe present, when BP maybe present, when BP is increased, cerebral is increased, cerebral manifestations may manifestations may occur such as, occur such as, headache, drowsiness, headache, drowsiness, diplopia, vomiting and diplopia, vomiting and convulsionsconvulsions

Laboratory findingsLaboratory findings Urine – shows heavy Urine – shows heavy albuminuriaalbuminuria

Urine – contains RBC and Urine – contains RBC and increase specific gravityincrease specific gravity

TreatmentsTreatments 1.1. PrednisonePrednisone

2.2. FurosemideFurosemide

3.3. Salt-poor albuminSalt-poor albumin

1.1. Antibiotics for strep Antibiotics for strep infectioninfection

2.2. Antihypertensives Antihypertensives and diureticsand diuretics

3.3. CorticosteroidsCorticosteroids

Nursing interventionsNursing interventions 1.1. Control edemaControl edema

2.2. Provide skin careProvide skin care

3.3. Prevent infectionPrevent infection

4.4. Monitor nutrition: Monitor nutrition: low Na, high CHON, low Na, high CHON, high potassiumhigh potassium

5.5. Monitor urine for Monitor urine for proteinuriaproteinuria

1.1. Bed rest if Bed rest if hypertensivehypertensive

2.2. Restrict fluidRestrict fluid

3.3. Monitor BPMonitor BP

4.4. Provide low Provide low potassium diet, no potassium diet, no added saltadded salt

5.5. Prevent infectionPrevent infection