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Pediatric Accidents

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

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Pediatric Accidents

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  1. Pediatric Accidents

  2. 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

  3. Common Pediatric Accidents • Head Trauma • Drowning/Near Drowning • Poisoning • Burns • Bodily Injury/Suicide

  4. Head Trauma

  5. 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.

  6. 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

  7. 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

  8. 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.

  9. 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.

  10. 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.

  11. 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 Infant Adaptations to GCS

  12. 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

  13. 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

  14. 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

  15. 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

  16. Medications • Anticonvulsants: seizure prevention • Osmotic and loop diuretics: deplete water from intracellular and interstitial compartments, decrease cerebral fluid volume and ICP • Steroids: decrease inflammation

  17. Common Pediatric Head Injuries • Skull fracture • Linear or depressed • Intracrainal Hemorrhage • Subdural Hematoma • Epidural Hematoma • Concussion • TBI

  18. 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

  19. Signs and Symptoms of Skull Fractures • Headache • Decreased LOC • Otorrhea, Rhinorrhea that tests positive for glucose • Unilateral hearing loss • Orbital or postauricular ecchymosis

  20. 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

  21. 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

  22. 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

  23. Subdural Hematoma • Caused by trauma or violent shaking that cause neurons bleed Signs & symptoms: • LOC changes-Confusion, irritability, lethargy • Ipsilateral pupil dilatation • Seizures • Vomiting • Retinal hemorrhage

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. Prevention Car Safety!

  30. Car Safety: Infants • Rear-facing seat from birth to 1 year and 20 lbs in a Five Point Harness

  31. 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

  32. Car Safety: Preschoolers and Older • 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

  33. How Does the Public Know if They Properly Installed their Child in a Car Seat?

  34. Drowning/Near Drowning

  35. 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.

  36. 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

  37. 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

  38. Poisoning

  39. 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

  40. Management of Poisoning Initial Intervention: Terminate Exposure! • empty mouth of pills, plants • flush eyes or skin • remove contaminated clothes

  41. Try to identify the poison • Take an accurate history 2. Physical Exam Neuro Resp Cardiac 3. Obtain Labs

  42. Intervention While waiting decision for intervention: • Maintain patent airway • Maintain effective breathing pattern • Maintain vital signs within normal range • Maintain body temperature

  43. Remove Poison, and Prevent Absorption Three ways of gastric decontamination: • Syrup of Ipecac • Gastric Lavage • Activated Charcoal

  44. 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

  45. 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…

  46. 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)

  47. 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

  48. Management • Gastric Lavage if within the 1st hr of ingestion • Then Activated charcoal • Mucomyst is antidote, however…

  49. 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

  50. 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

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