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 patients
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
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

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

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

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

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

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 childs behavior changes seek help

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

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 childs palm(approximately 1% of
the tbsa)
add the number of times the childs 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 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