lOMoARcPSD|11490250

Nursing Care of a Family When a Child has an Unintentional

Injury
Nursing (Bukidnon State University)

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HEAD TRAUMA - Assess children’s level of consciousness and motor

- Children receive head injuries when they are function.
involved in multiple-trauma accidents, such as - Stabilize the neck with a brace until cervical trauma
automobile crashes. Falls from swing sets, porches, has been ruled out.
and bunk beds also cause many head injuries. Other
children are injured by being struck on the head by Immediate Management
an object, such as a baseball, rock, or hockey puck, or After a head injury, brain edema is likely because fluid rushes
by falling from a bicycle into the inflamed and bruised area.
- Head injuries are always potentially serious not only - Both central venous and central arterial lines may
because they can cause an immediate threat to the be inserted.
life of the child, but also because several - ICP monitoring may be initiated
complications may follow. - A computed tomography (CT) scan or magnetic
- With a depressed skull fracture, for example, resonance imaging (MRI) will be ordered to
recurrent seizures can occur. determine areas of edema or bleeding. Assessment:
- Some children experience memory deficits or minor - An attempt may be made to decrease brain edema If the base of the skull is fractured, a child usually exhibits
personality changes after head injury (Fazio et al., by intravenous (IV) administration of a hypertonic orbital or postauricular ecchymosis.
2007). solution, such as mannitol. This will increase - Rhinorrhea or otorrhea (clear fluid draining from the
- Symptoms such as headache, irritability, and postural intravascular pressure and shift the edema fluid back nose or ear, respectively) may be present. This is
vertigo (sensation of feeling faint or the inability to into the blood vessels. escaping cerebrospinal fluid (CSF)—a serious finding,
maintain normal balance—also known as posttrauma - Steroids such as dexamethasone may be added to because it means that the child’s central nervous
syndrome) also may occur. decrease inflammation and edema. system is open to infection.
- Behavioral manifestations may include - Keeping the head elevated is also effective in - Test the fluid discharge with a glucose reagent strip
aggressiveness or poor school performance. It often reducing ICP. if there is doubt about the source of the drainage.
is difficult to determine whether these symptoms are CSF will test positive for glucose, whereas the clear,
organic or the result of being treated differently than SKULL FRUCTURE watery drainage from an upper respiratory tract
usual by anxious parents. A skull fracture is a crack in the bone of the skull infection will not.
Immediate Assessment - Recognizing skull fractures in children is important, - Take a careful history of the accident.
- All children with head trauma require a neurologic because associated cerebral injury often occurs Shock with hypotension rarely occurs with an isolated head
assessment as soon as they are seen and again at under the fracture. injury.
frequent intervals to detect signs and symptoms of - Many skull fractures are simple linear types, most - If a child is in shock, investigate for bleeding points
increased intracranial pressure (ICP). often involving the parietal bones. other than the head injury.
- Increasing pressure puts stress on the respiratory, - In some children, the skull does not fracture, but the - Skull fractures are confirmed by skull radiography. If
cardiac, and temperature centers, causing suture lines separate. This occurs more commonly in a skull fracture is linear with no underlying pathology,
dysfunction in these areas. the lambdoid suture line; a coronal suture separation no treatment except observation and prescription
- With increased pressure, the pupils become slow or is rare and, if present, indicates severe trauma (Fig. of an analgesic is necessary.
unable to react immediately. 52.1) - In about 3 weeks, a repeat radiograph will be
- Level of consciousness and motor ability decrease, needed to confirm that healing has taken place.
pulse and respiratory rates decrease, and - If a fracture is depressed (a bone fragment is pressing
temperature and pulse pressure increase. inward) or compounded (bone is broken into pieces),
- Assess vital signs to detect these changes and surgery will be necessary to remove or repair
observe children’s pupils to be certain that they are broken fragments. Cranial surgery of this type is
equal and react to light. discussed in Chapter 49.

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SUBDURAL HEMATOMA - This happens when head trauma is severe.

Therapeutic Management: - Subdural hemorrhage is usually venous bleeding, but
- It is venous bleeding into the space between the epidural hemorrhage is usually a result of rupture of
- If CSF is draining from the nose, a child will be dura and the arachnoid membrane. It occurs when the middle meningeal artery and is, therefore,
admitted to the hospital for observation. head trauma lacerates minute veins in this area arterial bleeding.
- Keep the child in a semi Fowler’s position so that - The collection of blood is usually bilateral. - It usually is intense and causes rapid brain
fluid drains out, not inward, to reduce the possibility - tend to occur in infants more often than in older compression.
of introducing infection. children. - At the time of the injury, children become
- Make certain that children do not attempt to hold - Symptoms may occur within 3 days or as late as 20 momentarily unconscious.
their nose or pack their nostrils with something to days after trauma. Infants usually have symptoms of - They then regain consciousness and, to the untrained
halt the drainage. increased ICP. eye, appear to be well for minutes or hours.
- Because coughing and sneezing may allow air to - Seizures, vomiting, hyperirritability, and - Then signs of cortical compression—vomiting, loss of
enter the meningeal space, coughing may be enlargement of the head may occur. consciousness, headache, seizures, or hemiparesis
suppressed by medication. - Anemia caused by the substantial blood loss is a (paralysis on one side)—are observed.
- If the drainage is excoriating to the upper lip, coat prominent sign. - On physical examination, unequal dilation or
the space with petrolatum. - Angiography or ultrasound reveals the extent of the constriction of the pupils may be present.
- Children may be prescribed a prophylactic antibiotic hematoma. - Decorticate posturing may be seen, indicating
to reduce the risk for meningitis. In infants, accumulated subdural blood may be removed by a extreme pressure on upper cortical centers. If the
- If the drainage does not stop within a few days, subdural puncture through the lateral aspect of a patent pressure is allowed to continue unchecked, cortical
surgery will be necessary to repair the fracture and anterior fontanelle. compression may be so great that brainstem,
reduce the danger of meningitis. - The procedure is similar to a lumbar puncture. respiratory, or cardiovascular function becomes
Air that enters intracranial spaces usually is absorbed - Infants receive conscious sedation or must be held impaired.
rapidly. extremely still during the procedure so that they do - As a rule, the closer to the time of the injury that
- If radiographs at 72 hours still show air in the not move and cause the aspiration needle to be symptoms of compression occur, the more extreme
cerebral spaces, it implies that a skull defect remains, inserted incorrectly. is the amount of blood loss.
and surgery may be indicated to close the defect. - Without conscious sedation, half of the success of - The treatment is surgical removal of the
subdural puncture depends on the ability to hold the accumulated blood and cauterization or ligation of
Potential Complications: child still. the torn artery.
- Subdural punctures may need to be repeated daily - The earlier the process is recognized and treated, the
A long-term complication of even a linear fracture may be a to empty the subdural space. less the chance of residual damage from extreme
leptomeningeal cyst. - Once the space is empty, expanding brain tissue will pressure or anoxia to the involved portion of the
- This results from projection of the arachnoid naturally occlude it. If the space has not been brain.
membrane into the fracture site. occluded after 2 weeks of daily punctures, active
- With the interfering tissue, bone cannot heal and bleeding is still present, and surgery usually is
actually erodes, so that the fracture site becomes necessary to reduce the space and halt bleeding.
progressively larger, not smaller. This becomes - In older children, surgery usually is necessary,
evident on a follow-up radiograph. because the anterior fontanelle is closed and the
- It may be suspected if a child develops focal seizures space cannot be reached by puncture.
or symptoms of increased ICP. The defect may be
palpated on the skull as an underlying indentation. EPIDURAL HEMATOMA
- Surgical resection is necessary to remove the cyst. - Epidural hematoma is bleeding into the space
between the dura and the skull

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- Parents usually are instructed not to keep waking

children during the night, because multiple wakings
are disorienting and can be confused with
unconsciousness.
- Parents should wake the child at least once during
the night, however, and assess that the pulse rate is
greater than 60 beats per minute.
- To be certain that children are alert, parents can ask
them to name a familiar object, such as a favorite
toy, or to name the color of some object shown to
them.
- Telling parents their name or where they live is
equally revealing.
- Advise them to call if their child’s behavior changes
CONCUSSION in any way that seems worrisome.
COMA
- Concussion is the temporary and immediate - Be certain they understand that it is all right for
impairment of neurologic function caused by a hard, children to sleep, but they must wake them at least
- Coma (unconsciousness from which a child cannot be
jarring shock once to assess their status
roused) or stupor (grogginess from which a child can
- It may occur on the side of the skull that was struck be roused) may be present in children after severe
(a coup injury) or on the opposite side of the brain (a head trauma.
contrecoup) - Coma and stupor are both symptoms of underlying
- As the brain recoils from the force of the blow and disorders; a history of the injury must be obtained
strikes the posterior surface of the skull, this second so that treatment can be directed specifically toward
injury occurs. the cause.
- Children have at least a transient loss of
consciousness at the time of the injury. They may Assessment:
vomit and may show irritability after regaining - Obtain a history to determine the circumstances
consciousness. immediately before the time the child became
- They typically have no memory (amnesia) of the comatose.
events leading up to the injury or of the injury itself. - Assess children in coma carefully and completely, so
- For some children, this makes being asked questions CONTUSION
- A brain contusion occurs when there is tearing or that the cause of the decreased consciousness can
about the accident extremely upsetting because they quickly be determined.
do not remember anything that happened and feel a laceration of brain tissue
- The symptoms are the same type as for concussion - Undress the child completely so that all body parts
frightening loss of control. can be inspected.
- The child requires a skull radiograph to rule out skull but more severe.
- In addition, there are specific symptoms related to - Although head injury is most likely to be the
fracture and observation for 24 hours to rule out underlying cause of coma or seizure, metabolic
severe brain trauma, edema, or laceration. the lacerated brain area such as a focal seizure, eye
deviation, or loss of speech. disturbances such as diabetes mellitus, dehydration,
- A child usually can be observed at home by the severe hemorrhage, or drug ingestion, also must be
parents, who are instructed to check the child’s level - Surgery may be necessary to halt bleeding. T
- The child’s prognosis depends on the extent of the considered as possible causes.
of consciousness every 1 to 2 hours while the child - Count respirations and pulse and measure blood
is awake. injury and effectiveness of therapy
pressure to establish baseline values, because

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changes in these values often provide good clues lumbar puncture, and toxicology tests may be - An IV route is established so that, when specific
regarding the cause of coma. ordered to rule out possible causes such as bacterial measures such as blood replacement, electrolyte
- A child with increased ICP, for example, will show meningitis or hemorrhage. replacement, or fluid replacement are needed, a
decreased pulse and respiratory rates and increased - Computed tomography (CT) or MRI will be done if a route for immediate administration will be available.
blood pressure. head injury is the most likely cause (Claret-Teruel et - Blood will be drawn for a complete blood count,
- Diabetes, in contrast, leads to increased respirations. al., 2007). electrolyte determination, toxicology tests, and
- Hemorrhage leads to an increased pulse rate and cross-matching.
decreased blood pressure. Coma is usually graded according to a standard scale so that - If the cause of the coma is unknown, a lumbar
- Drug ingestion may lead to either increased or changes in the level of consciousness can be evaluated puncture and EEG may be done.
decreased measurements, depending on the drug accurately. Figure 52.5 shows the Glasgow Coma Scale, a - Skull radiography, CT scan, or MRI may be done.
ingested. commonly used evaluation system (Morris, 2008). Because - Lumbar puncture has little value at first in predicting
If bulbar (brainstem) compression is present, a child this system was devised as an adult assessment scale, it must the severity of a head injury, because any degree of
cannot swallow effectively or safely. be modified for use with children or infants. (Check book for cerebral contusion usually leads to increased CSF
- If this is suspected, turn the child on the side to Modified) pressure. Lumbar puncture is contraindicated if
prevent aspiration. - A score of 3 to 8 on the scale suggests severe trauma increased ICP is present as release of fluid with the
- Observe the eyes for signs of increased ICP. If both (a number less than 5 suggests a very severe puncture can cause brainstem compression into the
pupils are dilated, irreversible brainstem damage is prognosis); a score of 9 to 12, moderate trauma; and cord.
suggested, although such a finding may also be 13 to 15, slight trauma - Obtain the child’s vital signs and assess neurologic
present with poisoning from an atropine-like drug. status, such as state of consciousness and the ability
- Pinpoint pupils suggest barbiturate or opiate of pupils to react to light, every 15 to 20 minutes or
intoxication. as ordered.
- One pupil dilated more than the other suggests third A child’s prognosis after coma depends on the initial cause of
cranial nerve compression. An eye may be deviated the coma.
downward and laterally as well. - If the increased ICP can be relieved before any
- This also may be caused by a tentorial tear permanent brain damage results, the effects of the
(laceration of the membrane between the coma will be transient.
cerebellum and cerebrum) and herniation of the - Prognosis is always guarded, however, because
temporal lobe into the torn membrane. This coma reflects a potential health problem for a child.
situation requires immediate surgery to correct
temporal compression. CHOKING GAMES
The retina of the eye should be examined for papilledema, Therapeutic Management
which will be present if increased pressure is long-standing - Adolescents, seeking an inexpensive way to
(more than 24 to 48 hours). If children are unconscious for longer than a transient period, experience a “rush” or euphoria, induce a partial or
- Lack of a doll’s eye reflex suggests that compression they usually are admitted to an observation unit for further complete loss of consciousness in themselves by
of the oculomotor nerves (third, fourth, or sixth) or assessment. intentionally depriving their brain of oxygen for a
of the brainstem is involved. - As a general rule, place a child who is comatose on short period of time by strangulation or hanging or
Observe for posturing, such as decerebrate posturing, the side to reduce the risk of aspiration. reducing the oxygen able to reach their nose by
which suggests cerebral compression and dysfunction. - Oral suctioning to remove mucus from the mouth some technique such as pulling a plastic bag over
Many laboratory studies are helpful in determining the cause and pharynx may be necessary. their head. Extreme hyperventilation to induce
of coma. - If a child has acute signs of respiratory difficulty, hypocapnia is yet another technique.
- Blood glucose, blood electrolytes, blood urea endotracheal intubation may be necessary to ensure - The practice may be seen as a rite of passage or
nitrogen (BUN), liver function tests, blood gas studies, respiratory function. initiation into a gang or club.

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- The practice is also known as erotic asphyxiation as checked visually for blood and to test for occult - Occasionally, a child notices radiated left shoulder
it also induces a sexual response. blood. pain while lying in a supine position (Kehr’s sign).
Unfortunately, the game results in injury and death. - A radiograph will show little about the spleen itself
- At least 82 adolescents between the age of 6 and 19 Attach the tube to low intermittent suction if the presence of
but may reveal a broken rib over the spleen,
have died in the United States as a result of the game. blood is established. An indwelling urinary (Foley) catheter is
suggesting the extent of the trauma to that area.
Of these 86.6% were male; the mean age was 13.3. also inserted to evaluate urine for blood and urine output.
Evidence of blood in the urine or decreased output may - An IV line is begun immediately for fluid replacement,
The majority of the deaths occurred while the
indicate accompanying kidney or bladder trauma. If the urine and an IV pyelogram or MRI will be done to rule out
adolescent was alone; over 90% of the parents of the
contains blood, an emergency IV pyelogram or ultrasound damage to the left kidney, which, because of its
child were unaware of the game (CDC, 2008a).
Injuries such as concussion, bone fractures, and tongue may be ordered. Be aware that having NG tubes or catheters location just behind the spleen, may also have
biting may occur from falling. passed is always frightening for a child (unsure of their suffered trauma.
- Teach parents that the game exists and to be aware anatomy, children have no clear idea where the tubes are - A complete blood count is done to estimate the
of signs that their child might be interested or going). extent of the blood loss. Blood is typed and cross-
participating in the game. An abdominal radiograph or ultrasound may be ordered to matched, so that blood for replacement can be
- Common signs are discussion of the game, bloodshot rule out a fractured pelvis, a condition that could contribute readied if necessary.
eyes, ligature marks on the neck, severe headaches, to blood loss. Air under the diaphragm on the radiograph - The child will be admitted to an observation unit if
disorientation, and the presence of choke collars, suggests gastric or intestinal rupture with escape of air from
the blood loss from rupture appears to be mild. If
ropes, scarves, or belts tied to bedroom furniture these organs into the peritoneal cavity.
bleeding is severe, immediate surgery, such as a
Some parents may not bring their child to an emergency
partial or total splenectomy.
ABDOMINAL TRAUMA department immediately after abdominal trauma, because
they are unaware that serious injury can result to this part of - After a splenectomy, children are very susceptible to
When children are brought to a health care facility after
the body. Without frightening them, explain that an injury infection, particularly pneumococcal infections.
suffering a multiple-injury trauma, several medical specialists
need not be obvious at first glance to be serious and need Therefore, a large percentage of children are
may be required: a neurosurgeon for consultation about a
head injury; an orthopedic physician for consultation about a care. They may ask why a radiograph is necessary. When their managed expectantly to see if the bleeding will halt
fractured extremity; and a thoracic surgeon to intubate or child is asked to turn on the radiograph table so that an without spleen removal.
investigate lung trauma. abdominal fluid level can be revealed, they may perceive this - Children who have their spleen removed are offered
Assessment as unnecessary manipulation of an injured child. the pneumococcal vaccine to protect them against
Abdominal trauma results from an object striking the Splenic Rupture pneumococcal infections.
abdomen - The spleen is the most frequently injured organ in
 Assess vital signs frequently until they are stable abdominal trauma, because it is usually palpable Liver Rupture
under the lower left ribs. It is frequently injured by - Livers are also more prone to rupture in children
 Hypotension (less than 80 mm Hg systolic pressure in
inappropriately applied seat belts in automobiles and than in adults, because the liver, like the spleen, is
an older child; less than 60 mm Hg in an infant)
by handlebar injuries in bicycle accidents. It is not completely sheltered by the rib cage in children.
usually suggests hemorrhage, which may be hidden
increasingly caused by snowboard injuries. - Children with liver rupture or laceration usually have
abdominal bleeding.
- Children with splenic injury have tenderness in the severe abdominal pain that is most marked on
 Children may have increasing pallor and rapid
left upper quadrant, especially on deep inspiration, inspiration, when the diaphragm descends and
respirations. If internal bleeding is present, blood
when the diaphragm moves down and touches the touches the liver.
pressure will show little improvement when IV fluid
is administered. spleen. Signs and Symptoms
 If abdominal trauma is suspected, an NG tube is - They may hold their left shoulder elevated, so that  Blood loss
passed and stomach contents are aspirated to be the diaphragm is raised on the left side, to keep this  Tachycardia
from happening.

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 Hypotension replacing it. If a tooth is replaced, it usually is wired - Particularly at risk are male adolescents, because
 Anxiety into place to hold it in good alignment. they may take dares to swim farther than their ability
 Pallor allows or may swim under the influence of alcohol,
Treatment
 Hematocrit will be low or falling. which impairs their decision-making ability and their
- The child receives a course of oral antibiotics, such
physical coordination.
Such children need to be prepared for immediate surgery, as penicillin, to prevent infection.
because the liver is a highly vascular organ, and blood loss - Only soft food must be eaten until the tooth has Pathophysiology of Drowning
from it is acute and possibly life-threatening. firmly adhered (approximately 2 weeks). - When children’s heads are submerged and they first
Occasionally, a communication between an artery and the inhale water, they cough violently from the irritation
bile duct occurs at the time of trauma. In this situation, If a blow to a child’s teeth was extensive, a radiograph
of the water in their nose and throat.
symptoms are not immediate, but gastrointestinal (GI) may be taken to rule out a mandibular or maxillary
- If they cannot get their head out of water at this
bleeding, such as hematemesis or melena, may occur in a few fracture. If a portion of a tooth cannot be located, the
possibility of aspiration must be considered and point, water will enter the larynx. This causes the
days. larynx to spasm, preventing any further water but
The child may have colicky upper abdominal pain that is confirmed or ruled out by a chest radiography.
In young children, often a tooth is not knocked out but is also air from entering the trachea, so asphyxia results.
relieved by emesis. Liver studies, such as a liver arteriogram,
pushed back up into the gum. These teeth gradually - If a child is ventilated at this point, treatment usually
are necessary to reveal the extent of the problem. After
regrow, and, although they may darken in color, they is very effective because there is little water in the
either liver or spleen surgery, children need careful
observation for return of bowel function, assessment for the usually are healthy. If the affected tooth is a deciduous lungs.
possibility that peritonitis may develop, and careful tooth, the permanent tooth is rarely injured even though - The condition more closely simulates asphyxia that
reintroduction of oral nutrition.careful observation for return it is already formed in the gum. m. At the appropriate occurs with croup or when a foreign body, such as a
of bowel function, assessment for the possibility that time, the permanent tooth will erupt normally. nut, lodges in the trachea and stops air flow.
peritonitis may develop, and careful reintroduction of oral NEAR DROWNING - If treatment is not given at this point, the larynx
nutrition. - Drowning is death caused by suffocation from relaxes from the asphyxia and water enters the lungs.
DENTAL TRAUMA submersion in liquid. Inhaled water fills the lungs
- Oxygen can no longer be exchanged, because the
- Injuries to teeth occur most often from falls in which and therefore blocks the exchange of oxygen in the alveoli fill with water. Hypoxia deepens, and cardiac
a child strikes the upper front incisors or from blows alveoli. More than 3500 children die from drowning arrest occurs.
to the face by objects such as baseball bats or hockey annually, making it the second most common cause - Additional changes that occur when water enters the
sticks. Such accidents are always potentially serious, of death by unintentional injury among children. lungs depend on whether the water is fresh or salt.
because they can lead to aspiration of the injured - The term near drowning is used to describe the child - Salt water is hypertonic, causing fluid to osmose
teeth or malalignment of future teeth. with a submersion injury who requires emergency from the bloodstream and enter the alveoli,
- If permanent teeth that have been knocked out treatment and who survives the first 24 hours after increasing the amount of fluid in the lung tissue and
recently can be washed with saline in the emergency injury.
increasing hypoxia. Tachycardia and decreased blood
department and replaced, there is a good chance - Most infant drownings occur in bathtubs; pressure from hypovolemia result. Blood viscosity
that they will reimplant successfully. - 1- to 4-year-old children most frequently drown in increases as shown by an increased hematocrit level.
- If a tooth is knocked out, parents should rinse the artificial pools;
- Fresh water is hypotonic, so fluid in the lungs shifts
tooth in water, drop it in a salt solution or milk, and - older children most frequently drown in bodies of into the bloodstream because of osmotic pressure.
bring it to the emergency department with them. fresh water. This can lead to hemolysis of red blood cells, a
- Some dentists advocate immersing the tooth in an - The majority of drowning accidents that take place dilution of plasma, and possibly hypervolemia with
antiseptic and then in an antibiotic solution before outside the home occur in the summer months, tachycardia and increased blood pressure.
when more children are swimming and boating.

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- If the release of potassium from destroyed red blood - Assuming that cardiopulmonary resuscitation is prognosis is greatly improved over that of the child
cells is great enough with fresh-water drowning, effective, the child needs follow-up care at a health who is comatose.
cardiac arrhythmias may occur. In both instances, care facility, because the child is certain to be
POISONING
loss of surfactant from lung alveoli, caused by acidotic from accumulated carbon dioxide and
 Poisoning occurs most commonly in children between
introduction of water (adult respiratory distress hypoxia (resulting from lack of oxygen because of the
the ages of 2 and 3 years. It occurs in all socioeconomic
syndrome), can lead to alveolar collapse on water in the alveoli) and is at risk for respiratory
groups.
expiration infection from contaminants in the water.
 Common agents include soaps, cosmetics, detergents or
- Parents should advocate for neighborhood pools to - Follow-up care aims to increase the child’s oxygen
cleaners, and plants. Poisoning can occur from over-the-
be fenced and advise against hyperventilating before and carbon dioxide exchange capacity, using the lung
counter drugs, such as vitamins, iron compounds, aspirin,
swimming. areas that are not filled with water.
or acetaminophen, or from prescription drugs, such as
- When children blow off carbon dioxide with - Typically, a child is intubated with a cuffed
antidepressants.
hyperventilation this way, and then swim intratracheal tube; mechanical ventilation with
underwater for an extended period of time, carbon positive end-expiratory pressure may be necessary to  Unlike other unintentional injuries, poisoning is entirely
dioxide levels will rise, but not adequately enough to force air into the alveoli. preventable. Parents need education about the high risk
cause them to experience distress. - Because water has been swallowed, vomiting usually for poisoning and strategies for maintaining a home
- Oxygen levels decrease causing drowsiness and occurs as the child is revived. The cuff of the environment that is safe for children of all ages. Be aware
listlessness (children drown without struggling or intratracheal tube prevents vomitus from being that when poisoning occurs in an older child, it may not
realizing their danger). aspirated. be poisoning but a suicide attempt.
- Very young children display a mammalian diving - The child is given 100% oxygen so that as much space Emergency Management of Poisoning at Home
reflex when they plunge under cold water that helps as possible in the available lung alveoli can be used.  If poisoning occurs, parents should telephone their local
them survive drowning. - An NG tube is inserted to decompress the stomach, poison control center to ask for advice. Information
- Immediately after plunging into cold water, a prevent vomiting, and free up breathing space. parents need to provide includes:
lifesaving bradycardia and shunting of blood away - albuterol is administered by aerosol to prevent o Child’s name, telephone number, address, weight,
from the periphery of the body to the brain and bronchospasm and, again, to allow the child to make and age and what the child swallowed
heart occur. maximum use of the oxygen administered. o How long ago the poisoning occurred
- This reflex is triggered when water is 70° F (21° C) or - If the child aspirated salt water, plasma may be o The route of poisoning (oral, inhaled, sprayed on skin)
less and the face is submerged first. administered to replace protein being lost into the o How much of the poison the child took (the bottle
- This explains why very young children can survive lungs and prevent hypovolemia. should say how many pills or liquid it originally held).
better than older children after being submerged in - If the child’s body temperature is very low, gradual o If the poison was in pill form, whether there are pills
water that is very cold warming (not using a warming blanket) is advised so scattered under a chair or if they are all missing and
that the metabolic requirement does not rise sharply presumed swallowed
Emergency Management
before alveolar space is ready to accommodate this o What was swallowed; if the name of a medicine is
- When a child is pulled from the water after near
need. Extracorporeal membrane oxygenation may be not known, what it was prescribed for and a
drowning, mouth-to-mouth resuscitation should be
used. description of it (color, size, shape of pills)
started at once.
- Unfortunately, neurologic damage occurs in as many o The child’s present condition (sleepy? hyperactive?
- If cardiac arrest has occurred from hypoxia,
as 21% of near-drowning incidents. If the child is comatose?)
simultaneous measures to initiate cardiac action
awake or only lethargic at the scene of the accident  If one child has swallowed a poison, parents should
must be taken.
and immediately afterward in the hospital, the investigate whether other children have also poisoned

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themselves as a preschooler often shares “candy” with a  Soon, serum aspartate transaminase (AST [SGOT]) and o The child may immediately vomit blood, mucus, and
younger sibling serum alanine transaminase (ALT [SGPT]), liver enzymes, necrotic tissue.
become elevated. o The loss of blood from the denuded, burned surface
Emergency Management of Poisoning at the Health Care
 The liver may feel tender as liver toxicity occurs. Parents may lead to systemic signs of tachycardia, tachypnea,
Facility
should call their local poison control center. pallor, and hypotension.
 In the emergency department, the best method to
 In the emergency department, activated charcoal or o A chest radiograph may be ordered to determine
deactivate a swallowed poison is the administration of
acetylcysteine, the specific antidote for acetaminophen whether pulmonary involvement has occurred from
activated charcoal, either orally or by way of an NG tube.
poisoning, will be administered. any aspirated poison or whether an esophageal
 Activated charcoal is supplied as a fine black powder that
 Acetylcysteine prevents hepatotoxicity by binding with perforation has allowed poison to seep into the
is mixed with water for administration.
the breakdown product of acetaminophen so that it will mediastinum.
 A sweet syrup may be added to the mixture to make it
not bind to liver cells. o An esophagoscopy under conscious sedation may be
more palatable.
 Unfortunately, acetylcysteine has an offensive odor and done to assess the esophagus, although this test may
 Caution parents that, as the charcoal is excreted through
taste. Administer it in a carbonated beverage to help the be omitted because of the possibility that an
the bowel over the next 3 days, stools will appear black
child swallow it. esophagoscope might perforate the burned
(Box 52.6).
 For small children, it is administered directly into an NG esophagus.
 Always follow emergency measures to neutralize a o After 2 weeks, a barium swallow or esophagoscopy
tube to avoid this difficulty.
poison with an education program for the family to may be performed to reveal the final extent of the
prevent poisoning from happening again.  If the child is admitted to an observation unit, continue
to observe for jaundice and tenderness over the liver; esophageal burns.
 Specific measures for each age group are discussed in
assess ALT and AST levels as ordered
previous chapters, along with problems and concerns of THERAPEUTIC MANAGEMENT
that age group. o When parents whose child has ingested a caustic
CAUSTIC POISONING substance call a poison control center to ask for
 Ingestion of a strong alkali, such as lye, which is often advice on how to proceed, they will be advised to
ACETAMINOPHEN POISONING
contained in toilet bowl cleaners or hair care products, immediately take the child to a health care facility for
 Acetaminophen (Tylenol) is the drug most frequently
may cause burns and tissue necrosis in the mouth, treatment.
involved in childhood poisoning today, because parents
esophagus, and stomach. o There is a high possibility that pharyngeal edema will
use acetaminophen to treat childhood fevers.
 It is important that the parents do not try to make a be severe enough to obstruct the child’s airway by
 Told that acetaminophen is safer than aspirin, parents
child vomit after ingestion of these substances, because even 20 minutes after the burn.
may not be as careful about putting this drug away as
they can cause additional burning as they are vomited o To detect respiratory interference, assess vital signs
they were with aspirin.
 If their child swallows acetaminophen, they may delay closely, especially the respiratory rate.
ASSESSMENT o In infants, increasing restlessness is an important
bringing the child for help, thinking it is a harmless drug.
o After a caustic ingestion, the child has immediate pain accompanying sign of oxygen want. In the emergency
 Acetaminophen in large doses, however, is not an
in the mouth and throat and drools saliva because of department, intubation may be necessary to provide
innocent drug; it can cause extreme liver destruction
oral edema and an inability to swallow. a patent airway.
(Morgan & Borys, 2008).
o The mouth turns white immediately from the burn. o Assess the child also for the degree of pain involved.
 Immediately after ingestion, the child will experience
o Later, the mouth turns brown as edema and o A strong analgesic, such as morphine, may need to be
anorexia, nausea, and vomiting.
ulceration occur. There may be such marked edema of ordered and administered to achieve pain relief
the lips and mouth that it is difficult to examine them.
HYDROCARBON INGESTION

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 Hydrocarbons are substances contained in products such o Parents should contact their poison control center  Kidney destruction may occur in addition, causing excess
as kerosene and furniture polish. immediately after the ingestion. excretion of amino acids, glucose, and phosphates in the
 Because these substances are volatile, fumes rise from o In the emergency department, stomach lavage will be urine.
them, and their major effect is respiratory, not gastric, done to remove any pills not yet absorbed.  The most serious effect, however, is lead encephalitis:
irritation o A cathartic may be given to help the child pass inflammation of brain cells because of the toxic lead
enteric-coated iron pills. content.
IRON POISONING o Activated charcoal is NOT given, because it is not  Lead poisoning (plumbism), like all forms of poisoning in
 Iron is frequently swallowed by small children because effective at neutralizing iron. children, tends to occur most often in the toddler or
it is an ingredient in vitamin preparations, particularly o A soothing compound such as Maalox or Mylanta preschool child.
pregnancy vitamins. (aluminum hydroxide and magnesium hydroxide)
 When it is ingested, it is corrosive to the gastric mucosa may be given to help decrease gastric irritation and ASSESSMENT
and leads to signs and symptoms of gastric irritation pain. o Lead poisoning is said to be present when the child
 The immediate effects include nausea and vomiting, o A child who has ingested a potentially toxic dose will has two successive blood lead levels greater than 10
diarrhea, and abdominal pain. be given a chelating agent, such as IV or ug/dL.
 After 6 hours, these symptoms fade, and the child’s intramuscular (IM) deferoxamine. o The usual sources of ingested lead are paint chips or
condition appears to improve. By this time, however, o Chelating agents combine with metals and allow them paint dust, home-glazed pottery, or fumes from
hemorrhagic necrosis of the lining of the GI tract has to be excreted from the body. burning or swallowed batteries (Olson, 2009).
occurred. o Caution parents that deferoxamine causes urine to o Paint tastes sweet, and a child will repeatedly pick
 By 12 hours, melena (blood in stool) and hematemesis turn orange as iron is excreted. chips up off the floor or off the walls.
(blood in emesis) are present. o An exchange transfusion is another way that excess o If a crib rail is painted with lead paint, a child will
 Lethargy and coma, cyanosis, and vasomotor collapse iron can be removed from the body. ingest it as the child teethes on the rail.
may occur. o An upper GI x-ray series and liver studies may be o Chewing on windowsills is also common. In fishing
 Coagulation defects may occur, and hepatic injury also ordered 1 week after the ingestion to screen for long- communities, swallowing lead sinkers can be a
can result. term effects. common source.
 Shock resulting from an increase in peripheral vascular o The hope is that the iron load was removed from the o Restoring an older home saturates the air with lead
resistance and decreased cardiac output can occur. stomach in time so that not all of it was absorbed. dust. In such homes, lead plumbing also may
 Long-term effects can include gastric scarring from o Assist with emergency measures, such as gastric contaminate the drinking water
fibrotic tissue formation. lavage, and administer chelating agents as ordered. o Many children with fairly high blood lead levels are
o Parents may be asked to test any stool passed for the asymptomatic. Others show insidious symptoms of
ASSESSMENT next 3 days for occult blood, to assess for stomach anorexia and abdominal pain caused by the presence
o It is difficult to estimate the amount of iron a child irritation and subsequent GI bleeding. of lead in the stomach.
has swallowed, because parents can only guess at the o Children with encephalopathy usually have beginning
number of pills in the bottle. LEAD POISONING
symptoms of lethargy, impulsiveness, and learning
 When lead enters the body, it interferes with red blood
o In addition, the amount of elemental iron in difficulties.
cell function by blocking the incorporation of iron into
compounds varies. The child’s serum iron level o As the child’s blood level of lead increases, severe
the protoporphyrin compound that makes up the heme
should be measured to establish a baseline. encephalopathy with seizures and permanent
portion of hemoglobin in red blood cells (Morgan &
neurologic damage will result.
Borys, 2008).
THERAPEUTIC MANAGEMENT
 This leads to a hypochromic, microcytic anemia.

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o The most widely used method of screening for lead o After some months, the new paint will begin to peel CLASSIFICATION OF LEAD POISONING RISK
levels is the blood lead determination (serum because of the defective paint underneath. The walls Class Lead Recommended
ferritin). must therefore be covered by paneling or Masonite. Blood Action
o Unfortunately, this test requires the use of atomic o All children with lead levels greater than 20 ug/100 Level
absorption spectrophotometry, which is a costly mL may be prescribed an oral CHELATING AGENT Conc.
procedure. such as SUCCIMER (ug/dL)
o The free erythrocyte protoporphyrin test is a simple o Children with blood lead levels of greater than 45 Class I (low risk) <9 Retest at 24
months for
screening procedure that involves only a fingerstick. ug/100 mL may be admitted to the hospital for
children age 6–35
o Because protoporphyrin is blocked from entering CHELATION THERAPY with agents such as
months who
heme by the lead, it will be elevated in a child with DIMERCAPROL (BAL) or EDETATE CALCIUM are considered low
lead poisoning. DISODIUM (CaEDTA) (Karch, 2009). risk; retest every 6
o Basophilic stippling (an odd striation of basophils) o Chelating agents remove the lead from soft tissue and months for ages
may be apparent on a blood smear. bone (although not from red blood cells), allowing it to 6–35 months who
o A radiograph of the abdomen may reveal paint chips be eliminated in the urine. are considered
in the intestinal tract (Fig. 52.6A). o Injections of EDTA, which must be given IM into a high risk
o “Lead lines” (areas of increased density) may be large muscle mass, are painful and may be combined Class IIa 10–14 Retest yearly;
present near the epiphyseal line of long bones (see Fig. with 0.5 mL of procaine. (rescreen) continue retesting
52.6B). o EDTA also removes calcium from the body; therefore, yearly for
o The thickness of the line shows the length of time serum calcium must be measured periodically to children >36
lead ingestion has been occurring (Kosnett, 2007). determine whether it is at a safe level. months until age 6
years
o Damage to the kidney nephrons from the presence of o Measure intake and output to ensure that kidney
Class IIb 15–19 Retest every 3–4
lead leads to proteinuria, ketonuria, and glycosuria. function is adequate to handle the lead being
(moderate risk) months for
o Urine analysis reveals this. excreted.
children age 6–35
o The CSF may have an increased protein level. o BUN, serum creatinine, and protein in urine may also months
be assessed to ensure that kidney function is Class III (high 20–44 Retest every 3–4
THERAPEUTIC MANAGEMENT adequate. risk) months; begin
o A child with a blood lead level between 10 and 14 o If kidney function is not adequate, EDTA may lead to home abatement
ug/dL needs to be rescreened to confirm the level. nephrotoxicity or kidney damage. program
o If the lead level is 15 ug/dL or higher, a child needs o BAL has the advantage of removing lead from red Class IV (urgent 45–69 Initiate chelating
active interventions to prevent further lead exposure. blood cells, but, because of severe toxicity, it is used risk) therapy and
o These interventions may include removal of the child only for children who have severe forms of lead environmental
from the environment containing the lead source or intoxication. remediation
removal of the source of lead from the child’s o Penicillamine (Cuprimine) is yet another drug used for Class V (urgent >70 Immediately treat
environment. lead poisoning. It is given orally after BAL or EDTA. risk) with a chelating
o Removal of the lead source can be difficult. If the Weekly complete blood cell counts and renal and liver agent
family lives in a rented apartment, the landlord may function tests accompany the administration of
PESTICIDE POISONING
be legally obligated to remove the lead. penicillamine. It may be given for as long as 3 to 6
o Simple repainting or wallpapering does not remove a months.
source of peeling paint adequately.

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 Pesticide poisoning can occur by accidental ingestion or  Parents should phone their poison control center for for drugs or what could be missing from the medicine
through skin or respiratory tract contact when children specific emergency steps. cabinet (provided the child became ill while at home).
play in an area that has recently been sprayed. o Expect to obtain blood specimens for electrolyte
POISONING BY DRUGS OF ABUSE levels and a toxicology screen. If the child is vomiting,
 Long-term exposure may result from exposure to a
 Adolescents and even grade-school children are brought
parent’s clothing if the parent comes home covered with save any vomitus for analysis. Try to determine
to health care facilities by parents or friends because of a
pesticide spray. whether the ingestion was an accident (perhaps the
drug overdose or a “bad trip” caused by an unusual
 Although pesticide poisoning was once thought to be child was unaware that two drugs would react this
reaction or the effect of an unfortunate combination of
only a rural problem, the increase in the use of lawn way or took a wrong dose) or whether the child was
drugs.
sprays by commercial lawn care companies now makes actually attempting suicide.
 Typical drugs involved include codeine and o All poisonings or drug ingestions in children older than
this a suburban problem as well (Olson, 2009).
antidepressant drugs. 7 years of age should be considered potential
 Many pesticides have an organophosphate base that
 Frequently, the drugs taken were prescription drugs suicides until established otherwise.
causes acetylcholine to accumulate at neuromuscular
removed from the family medicine cabinet (Schiesser, o If the ingestion was an accident, the child will need
junctions; this accumulation leads to muscle paralysis.
2007). counseling to avoid drug use or about which drugs do
 Within a few minutes to 2 hours after exposure, children
 Children are often extremely disoriented after this form not mix.
develop nausea and vomiting, diarrhea, excessive
of ingestion. o If the incident was an attempted suicide, the child
salivation, weakness of respiratory muscles, confusion,
 They may be having hallucinations. will need observation and counseling toward more
depressed reflexes, and possibly seizures.
 Obtaining a history may be difficult because children may effective coping mechanisms in self-care.
 In the emergency department, activated charcoal may be
have no idea what they took except that it was a red or a
administered if the pesticide was swallowed.
yellow capsule. THERAPEUTIC MANAGEMENT
 If clothing is contaminated, remove it and wash the
 They may know but may be reluctant to name a drug if it o Children need supportive measures for their specific
child’s skin and hair. To prevent coming in contact with
was obtained illegally. symptoms, including oxygen administration,
the pesticide yourself, wear gloves while bathing the
child. electrolyte replacement (particularly if there is
ASSESSMENT accompanying nausea and vomiting), and perhaps IV
 Intravenous atropine and a cholinesterase reactivator,
o Although a child may not appear to hear well or may fluid administration in an attempt to dilute the drug.
pralidoxime (Protopam Chloride) are effective antidotes
not seem coherent, try to elicit a history. o Children who have swallowed a drug of abuse need
to reverse symptoms.
o Avoid shouting or aggravating, because children who immediate treatment followed by investigation into
 If parents apply a pesticide to children to help avoid
are having a paranoid reaction will be unable to cope the events leading to the poisoning.
mosquito bites to reduce exposure to West Nile virus
rationally with this approach. o This potentially lethal ingestion may act as a turning
infection or tick bites to reduce exposure to Lyme disease,
o If friends accompany an ill child, point out that your point in the child’s life, possibly alerting the child and
diethyltoluamide (DEET)-based pesticides appear to be
role is not that of a law enforcer. family to a drug problem and the need for help.
safe if used sparingly, not applied to a child’s face, and
o Your role is to help the child, and you cannot do that Factors such as reduction of fear and anxiety,
washed off when the child returns indoors (AAP, 2008).
effectively unless the drug is identified. increased coping mechanisms, knowledge of the
PLANT POISONING o Approaching a child’s friends in this way is more likely effects of drug use, and availability of referral sources
 Plant poisoning (ingestion of a growing plant) occurs to result in their naming the drug. for a drug problem are important areas to address.
because parents commonly do not think of plants as o If a child is brought in by parents who have no idea
being poisonous what drug could possibly have been taken, ask them FOREIGN BODY OBSTRUCTION
 Common plants to which children may be exposed and to have someone at home check the child’s bedroom
the effects of ingestion are

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 Foreign bodies can become lodged in children’s FOREIGN BODIES IN THE NOSE that the coin does pass through the GI tract (about 48
esophagus, ear canals, or noses, causing stasis of  Foreign objects stuffed into the nose eventually cause hours after ingestion).
secretions and infection. inflammation and purulent discharge from the nares.  Without frightening them, caution parents to observe for
 Direct obstruction or laceration of the mucous  The odor accompanying such impaction is often the first signs of bowel perforation or obstruction, such as
membrane may also result, leading to serious sign noticed by a parent. vomiting or abdominal pain, until the object has passed.
consequences.  Objects pushed into the nose usually can be removed  If there is any doubt, a radiograph taken 3 to 7 days after
 Whether a foreign substance is inhaled or embedded with forceps. ingestion will establish whether the object has been
elsewhere, nursing interventions should focus first on  A local antibiotic might be necessary after removal if evacuated from the body.
comforting the child and aiding in removal of the ulceration resulted from the local irritation.
SUBCUTANEOUS OBJECTS
substance, and then on teaching the child and parents
Foreign Bodies in the Esophagus or Stomach  Children receive many wood splinters in the hands and
ways to avoid such occurrences in the future.
 Children tend not to chew food well or to swallow feet.
FOREIGN BODIES IN THE EAR portions that are too big to pass safely through the  These usually are removed easily by a probing needle
 Any child with a history of draining exudate from the ear esophagus. and tweezers after cleaning with an antiseptic solution.
canal needs an otoscopic examination to establish the  Pieces of candy, such as Lifesavers, are common objects  If the penetrating object is metal, such as a sewing
reason for the drainage. caught in the esophagus in young children; coins may be needle or nail, its presence can be detected by
 In toddlers and preschoolers, the drainage often is the swallowed by adolescents playing drinking games. radiography.
result of a foreign body in the ear canal.  Orthodontic appliances may become dislodged and  If the object is one that would have been in contact with
 The object might be a small piece of a toy, a piece of swallowed. soil, such as a rusty nail, the child will need tetanus
paper, a small battery, or food, such as a peanut (Singh et  Intense pain at the site where the object is lodged will prophylaxis after extraction of the object if tetanus
al., 2007). result. immunization is not current.
 Removal of a foreign body from the ear is difficult  If it is an object that will dissolve, such as a Lifesaver or a
BITES
because children are afraid that the instrument used will piece of digestible meat, offer the child fluid to drink to
 Children receive bites from snakes and animals such as
hurt them, so they have difficulty lying still for the help flush the object into the stomach.
dogs or raccoons; they occasionally receive bites from
procedure.  Even after the object dissolves or passes into the
other children.
 If there is reason to think that the tympanic membrane is stomach, the child will feel transient pain at the original
 The source of a bite needs to be documented as human
intact, irrigating the object from the ear canal with a site of the obstruction.
bites can also result from sexual abuse.
syringe and normal saline may be possible.  Magnets, particularly those in watches or hearing aids,
 This should NOT be done if the object is a substance are also frequently swallowed by young children. These MAMMALIAN BITES
that will swell when wet, such as a peanut. need to be removed by endoscopy as soon as possible as  Dog bites account for approximately 90% of all bites
 If it is possible that the tympanic membrane is ruptured, they can lead to bowel perforation or volvulus inflicted on humans, and children and adolescents are
the ear canal must not be irrigated or fluid will be forced  Objects, such as a part of a toy or a chicken bone, that involved in one third to one half of reported incidents.
into the middle ear, possibly introducing infection (otitis will not dissolve and should not be passed, are also  The dog is usually one owned by the child’s family.
media). removed by endoscopy  Cat bites, wild animal bites, and human bites also
 Often, it is better to wait for an otolaryngologist to care  Small coins, such as pennies and dimes, usually pass by constitute a threat, although they are less common in
for the child, because trauma to the ear canal during an themselves without difficulty. children.
attempt to remove a foreign body will increase the  Parents (or children themselves if adolescents) should  All of these bites can cause abrasions, puncture wounds,
edema and make removal even more difficult observe stools over the next several days to determine lacerations, and crushing injuries related to the size of
the animal and the location of the bite

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 The biggest concerns associated with animal bites are the o The pupils may be dilated, showing the potent effect o Specific antivenin is then administered. Because
possibility of longterm scarring and disfigurement and on cerebral centers. rattlesnakes, copperheads, and cottonmouth
the possibility of infection, especially rabies, from the o If the envenomation is not treated, seizures, coma, moccasins are all one type of snake (pit vipers), one
presence of microorganisms in the animal’s mouth. and death may result form of antivenin acts against all of these bites.
o Specific antivenin is prepared for coral snake or
SNAKEBITE
Emergency Management at the Scene cobra bites and is kept at most zoos.
 In the United States, snakebites tend to occur during the
o At the scene of a snakebite, apply a cold compress to o If the child receives antivenin promptly after a bite,
warm months of the year, from April to October.
the bite, in the hope of slowing the spread of the the prognosis for full recovery is good.
 Most fatal snakebites (envenomations) in the United venom and to reduce edema formation. o Tetanus prophylaxis is instituted if the child’s
States are copperhead or rattlesnake bites. o Urge the child to lie quietly, to slow circulation. immunization status is unknown or if it has been
 Copperheads are found in eastern and southern states, o Keep the bitten extremity dependent, again to slow more than 10 years since a tetanus immunization
and rattlesnakes in almost every state. venous circulation. was given.
 A few bites occur from cottonmouth moccasins or coral o Commercial snakebite kits have rubber suction cups o Antivenin may contain a horse-serum base.
snakes (both found in southeastern states). in them for suctioning out venom. If these are Therefore, before the serum is injected IM or IV, a
 The effect of the bite of a rattlesnake, copperhead, or available, they should be used at the site where the skin test may need to be performed to prevent a
cottonmouth moccasin (all pit vipers) is a failure of the bite occurred. possible anaphylactic reaction to the horse serum.
blood coagulation system (Clark, 2007). o Excising the bite with a knife and sucking out the o If the serum is given IM, do not inject it into an
 Coral snakes are known for the small coral, yellow, and venom orally (often shown in old western movies) is edematous body part, because medication
black rings encircling their body. of questionable value and contradicts rules of absorption will be poor.
 Fortunately, they are shy and seldom bite. However, the standard infection precautions. o Giving antivenin in the limb opposite the bitten limb
venom injected through the bite of these snakes leads to o If the person administering the treatment has open is just as effective as administering it into the bitten
neuromuscular paralysis mouth lesions, such as carious teeth, the procedure limb.
could be dangerous to that person (venom is not
ASSESSMENT THERMAL INJURIES
dangerous when swallowed, only when absorbed
o Reaction to a pit viper bite is almost immediate.  Thermal injuries include those caused by either cold
through open lesions).
o A white wheal forms at the site, showing the (frostbite) or by excessive heat (burns)
o Excising the bite also may lead to secondary infection
puncture marks, accompanied by excruciating pain  Frostbite
and, if done too vigorously, may injure tendon or
at the site. o Frostbite is tissue injury caused by freezing cold
muscle.
o Purplish erythema and edema begin to extend (Stallard, 2008).
o No time should be wasted before the child is
rapidly from the site. o Cold exposure leads to peripheral vasoconstriction,
transported to a health care facility for treatment.
o By the time a child is seen at a health care facility, cutting off the oxygen supply to surrounding cells.
sanguineous fluid may be oozing from the bite. o In children, the body parts involved usually are the
Emergency Management at the Health Facility
o Systemic symptoms, such as dizziness, vomiting, nose, fingers, or toes. Cells at the site can be so
o In the emergency facility, ask the child or a person
perspiration, and weakness, may be present. injured that they die.
who was with the child to describe the snake.
o Because snake venom interferes with blood o In areas where snakebites are frequent, keep
coagulation, the child may have hematemesis or ASSESSMENT
available photographs of the venomous snakes
bleeding from the nose, intestines, or bladder o The affected body part appears white or
commonly found. Even a preschooler may be able to
because of subcutaneous or internal hemorrhage. erythematous; edema is present and it feels numb.
identify the snake by pointing to a photograph.

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o Explore the cause of frostbite by careful history loss of body part Classification Description
taking.
o It occurs most frequently in children who have been Minor First-degree burn or
skiing, snowmobiling, or snowboarding for long seconddegree burn "10% of body
BURNS
periods. surface or third-degree burn "2%
 Burns are injuries to body tissue caused by excessive heat
o If parents failed to provide adequate clothing of body surface; no area of the
(heat greater than 104° F [40° C]).
because they underestimated the degree of cold face, feet, hands, or genitalia
 Such injuries commonly occur in children of all ages after
outside, the possibility of neglect or child abuse burned
infancy.
must be ruled out as a cause.  They are the second greatest cause of unintentional Moderate Second-degree burn between
o Frostbite also can occur from sucking on popsicles injury in children 1 to 4 years of age and the third 10% to 20% or on the face, hands,
and from inhalant abuse. greatest cause in children age 5 to 14 years. feet, or genitalia or third-degree
 Toddlers are often burned by pulling pans of scalding burn "10% of body surface or if
THERAPEUTIC MANAGEMENT water or grease off the stove and onto themselves or smoke inhalation has occurred
o Always warm frostbitten areas gradually. Sudden from bath water that is too hot. They can bite into
warming increases the metabolic rate of cells; Severe Second-degree burn #20% of
electrical cords.
without adequate blood flow to the area because of body surface or third-degree burn
 Older children are more apt to suffer burns from flames
still-present vasoconstriction, additional damage can #10% of body surface
when they move too close to a campfire, heater, or
occur. fireplace; touch a hot curling iron; or play with matches o Along with the size and depth, be certain to assess
o Administration of a vasodilator and use of or lighted candles. and document the location of the burn.
hyperbaric oxygen may help reduce the effect on
 Eye burns can occur from splashed chemicals in science o Face and throat burns are particularly hazardous
body cells.
classes). because there may be accompanying but unseen
 Some burns (particularly scalding) can be caused by child burns in the respiratory tract. Resulting edema could
Degrees of Frostbite
abuse). lead to respiratory tract obstruction.
Degree Description
 Burn injuries tend to be more serious in children than in o Hand burns are also hazardous because, if the fingers
First Mild freezing of epidermis; adults, because the same size burn covers a larger and thumb are not positioned properly during healing,
appears erythematous with surface of a child’s body. adhesions will inhibit full range of motion in the
edema  As many as 50% of burns could be prevented with future.
improved parent and child education. o Burns of the feet and genitalia carry a high risk for
Second Partial- or full-thickness injury; secondary infection.
appears erythematous with ASSESSMENT o Genital burns are also hazardous because edema of
blisters and pain occurring after o When children are brought to a health care facility the urinary meatus may prevent a child from voiding.
rewarming with a burn injury, the first questions must be, o With adults, the “rule of nines” is a quick method of
“Where is the burn and what is its extent and estimating the extent of a burn. For example, each
Third Full-thickness injury (epidermis,
depth?” upper extremity represents 9% of the total body
dermis, and subcutaneous
o Burns are classified according to the criteria of the surface; each lower extremity represents two 9s, or
tissue); appears white
American Burn Association as major, moderate, or 18%, and the head and neck represent 9%. Because
Fourth Complete necrosis with minor. the body proportions of children are different from
gangrene and possible ultimate

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those of adults, this rule does not always apply and is Second Epidermis Erythematous, Scalds heal
misleading in the very young child. Degree dry, painful
Portion of
o Computer analysis is now available to rapidly assess (Partial
Dermis
the extent of burns. Thickness)

Third Degree Entire skin, Leathery; black Flame

(Full including nerves or white; not
Data for determining the extent of burns in children
Thickness) and blood sensitive to
vessels in skin pain (nerve
endings
destroyed)

An infant with a first-degree burn on the arm

and chest caused by scalding with hot water.
o Second-Degree Burn
 Involves the entire epidermis. Sweat glands
and hair follicles are left intact. The area
appears very erythematous, blistered, and
moist from exudate. It is extremely painful.
 Scalds can cause second-degree burns.
 Such burns heal by regeneration of tissue but
take 2 to 6 weeks to heal.

o Depth Size
o When estimating the depth of a burn, use o First-Degree Burn
the appearance of the burn and the  Involves only the superficial epidermis. The
sensitivity of the area to pain as criteria. area appears erythematous. It is painful to
touch and blanches on pressure.
Characteristics of Burns
 Scalds and sunburn are examples of first-
Severity Depth of Tissue Appearance Example degree burns.
Involved  Such burns heal by simple regeneration and
take only 1 to 10 days to A toddler with a second-degree burn caused by scalding. The
First degree Epidermis Erythematous, Sunburn area appears severely reddened and moist with some blistering
(Partial dry, painful
Thickness) o Third-Degree Burn
 A third-degree burn is a full-thickness burn
involving skin layers, epidermis and dermis.

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 It may also involve adipose tissue, fascia, o A first-degree burn is painful, whereas a third- type of burn, they involve pain and death of
muscle, and bone. degree burn is not. Therefore, a child may be skin cells, so they must be treated seriously.
 The burn area appears either white or black. crying from a superficial burn that is obvious on o Immediately apply ice to cool the skin and
 Flames are a common cause of third-degree the arm, although the condition needing the prevent further burning.
burns. Because the nerves, sweat glands, most immediate attention is a third-degree o Application of an analgesic–antibiotic
and hair follicles have been burned, third- burn on the chest, which is covered by a jacket. ointment and a gauze bandage to prevent
degree burns are not painful. o Be certain to ask what caused the burn, because infection is usually the only additional
 Such burns cannot heal by regeneration different materials cause different degrees of burn. treatment required.
because the underlying layers of skin have Hot water, for example, causes scalding, a generally o The child should have a follow-up visit in 2
been destroyed. lesser degree of burn than one caused by flaming days to have the area inspected for a
 Skin grafting is usually necessary, and clothing. Ask where the fire happened. Fires in closed secondary infection and to have the dressing
healing takes months. Scar tissue will cover spaces are apt to cause more respiratory changed.
the final healed site. involvement than fires in open areas. o Caution parents to keep the dressing dry
 Many burns are compound, involving first-, o Ask whether the child has any secondary health (no swimming or getting the area wet while
second-, and thirddegree burns. problem. bathing for 1 week). A first-degree burn
 There may be a central white area that is o In their anxiety over the present burn, parents heals in about that time.
insensitive to pain (third degree), may forget to report important facts, such as  Moderate Burns
surrounded by an area of erythematous the child has diabetes or is allergic to a o Moderate or second-degree burns may have
blisters (second degree), surrounded by common drug. After a fire, parents may pick up blisters. Do not rupture them, because
another area that is erythematous only (first a burned child and bring the child to a health doing so invites infection.
degree). care facility, leaving other children unprotected o The burn will be covered with a topical
at home. antibiotic such as silver sulfadiazine and a
o Ask about other children and where they are. bulky dressing to prevent damage to the
o Parents may have burned hands from putting denuded skin.
out the fire on the child’s clothes and need o The child usually is asked to return in 24
equal care, but in their anxiety about the hours to assess that pain control is adequate
child’s condition, they do not mention this. and there are no signs and symptoms of
o Ask who put out the fire. Were any other family infection.
members or animals hurt? Does anyone else need o Broken blisters may be débrided (cut away)
care? to remove possible necrotic tissue as the
burn heals.
 Severe Burns
Emergency Management of Burns
o The child with a severe burn is critically
Full-thickness (third-degree) burn of the foot. Both layers of skin  All burns need immediate care because of the pain
injured and needs swift, sure care, including
are involved with this type of burn. involved
fluid therapy, systemic antibiotic therapy,
 Minor Burns
o Undress children with burns completely so the entire pain management, and physical therapy, to
o Although minor burns (typically first-degree
body can be inspected. survive the injury without a disability caused
partial-thickness burns) are the simplest
by scarring, infection, or contracture.

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 Electrical Burns of the Mouth o Some children have difficulty with speech  A synthetic skin covering (Biobrane), artificial skin
o If a child puts the prongs of a plugged-in sounds because of resulting lip scarring. (Integra), or amniotic membrane from placentas
extension cord into the mouth or chews on They need follow-up care by a plastic can be used to help decrease infection and protect
an electric cord, the mouth will be burned surgeon to restore their lip contour. granulation tissue.
severely. Obviously, you need to review with parents  As a rule, burn dressings are applied loosely for the
o Electrical current from the plug is conducted the importance of not leaving “live” first 24 hours to prevent interference with circulation
for a distance through the skin and electrical cords where young children can as edema forms.
underlying tissue, so a tissue area much reach them.  Be certain not to allow two burned body surfaces,
larger than where the prongs or cord such as the sides of fingers or the back of the ears
THERAPY FOR BURNS
actually touched is involved, leaving an and the scalp, to touch, because, as healing takes
 Second- and third-degree burns may receive open
angry-looking ulcer. place, a webbing will form between these surfaces.
treatment, leaving the burned area exposed to the
o If blood vessels were burned, active bleeding  Do not use adhesive tape to anchor dressings to the
air, or a closed treatment, in which the burned area
will be present. The immediate treatment skin; it is painful to remove and can leave excoriated
is covered with an antibacterial cream and many
for electrical burns of the mouth is to unplug areas, which provide additional entry for infection.
layers of gauze.
the electric cord and control bleeding.  Netting is useful to hold dressings in place, because it
Method Description Advantages Disadvantages
Pressure applied to the site with gauze is expands easily and needs no additional tape.
usually effective. Open Burn is Allows Requires strict
o Most children are admitted to a hospital for exposed to air; frequent isolation to  Topical Therapy
at least 24 hours in an observation unit used for inspection of prevent o Silver sulfadiazine (Silvadene) is the drug of
because edema in the mouth can lead to superficial site’ allows infection; area choice for burn therapy to limit infection at the
airway obstruction. Supply adequate pain burns or body child to follow may scrape burn site for children.
relief as long as necessary. parts that are healing process and bleed o It is applied as a paste to the burn, and the area
o Clean the wound about four times a day prone to easily and is then covered with a few layers of mesh gauze.
with an antiseptic solution, such as half- infection, such impede o Silver sulfadiazine is an effective agent against
strength hydrogen peroxide, or as otherwise as perineum healing both gram-negative and gram-positive
ordered to reduce the possibility of infection organisms and even against secondary infectious
(a real danger in this area, because bacteria Closed Burn is Provides better Requires
agents, such as Candida.
are always present in the mouth). covered with protection dressing
o It is soothing when applied and tends to keep the
o Eating will be a problem for the child non-adherent from injury; is changes that
burn eschar soft, making débridement easier. It
because the mouth is so sore. The child may gauze; used easier to turn are painful;
does not penetrate the eschar well, which is its
be able to drink fluids from a cup best. Bland for moderate and position possibility of
one drawback.
fluids, such as artificial fruit drinks or flat and severe child; allows infection may
o Antiseptic solutions, such as povidone-iodine
ginger ale, are best. burns child to more increase
(Betadine), may also be used to inhibit bacterial
o Electrical burns of the mouth turn black as freedom to because of
and fungal growth. Unfortunately, iodine stings
local tissue necrosis begins. They heal with play dark, moist
as it is applied and stains skin and clothing brown.
white, fibrous scar tissue, possibly causing a environment
Dressings must be kept continually wet to keep
deformity of the lip and cheeks with healing. them from clinging to and disrupting the healing
This can be minimized by the use of a mouth tissue.
appliance, which helps maintain lip contour.

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o If Pseudomonas is detected in cultures, o Children usually have 20 minutes of o Another trend in débridement is the use of
nitrofurazone (Furacin) cream may be applied. If hydrotherapy before débridement to soften and collagenase (Santyl), an enzyme that dissolves
a topical cream is not effective against invading loosen eschar, which then can be gently devitalized tissue.
organisms in the deeper tissue under the eschar, removed with forceps and scissors.  Grafting
daily injections of specific antibiotics into the o Débridement is painful, and some bleeding o Homografting (also called allografting) is the
deeper layers of the burned area may be occurs with it. placement of skin (sterilized and frozen) from
necessary. o Premedicate the child with a prescribed cadavers or a donor on the cleaned burn site.
o If a burned area, such as the female genitalia, analgesic, and help the child use a distraction o These grafts do not grow but provide a protective
cannot be readily dressed, the area can be left technique during the procedure to reduce the covering for the area. In small children,
exposed. The danger of this method is the level of pain. heterografts (also called xenografts) from other
potential invasion of pathogens. o Transcutaneous electrical nerve stimulation sources, such as porcine (pig) skin, may be used.
(TENS) therapy or patient-controlled analgesia o Autografting is a process in which a layer of skin
may also be helpful. of both epidermis and a part of the dermis (called
o Praise any degree of cooperation. Plan an a split-thickness graft) is removed from a distal,
 Escharotomy enjoyable activity afterward to aid in pain relief unburned portion of the child’s body and placed
o An eschar is the tough, leathery scab that forms and also to help re-establish some sense of at the prepared burn site, where it will grow and
over moderately or severely burned areas. control over the situation. replace the burned skin.
o Fluid accumulates rapidly under eschars, putting o Children need to have a “helping” person with o Cultured epithelium is derived from a
pressure on underlying blood vessels and nerves. them, to hold their hand, to stroke their head, fullthickness skin biopsy. This can be grown into
o If an extremity or the trunk has been burned so and to offer some verbal comfort during a coherent sheet and supply an unlimited source
that both anterior and posterior surfaces have débridement: “It’s all right to cry; we know that for autografts. Larger areas may require mesh
eschar formation, a tight band may form around hurts. We don’t like to do this, but it’s one of the grafts (a strip of partial-thickness skin that is slit
the extremity or trunk, cutting off circulation to things that makes burns heal” at intervals so that it can be stretched to cover a
distal body portions. o Nursing personnel need a great deal of talk time larger area.
o Distal parts feel cool to the touch and appear to voice their feelings about assisting with or o The advantage of grafting is that it reduces fluid
pale. The child notices tingling or numbness. doing débridement procedures. Be careful when and electrolyte loss, pain, and the chance of
o Pulses are difficult to palpate, and capillary refill serving as the “helping” person that you do not infection.
is slow (longer than 5 seconds). project yourself as the healer and comforter and o After the grafting procedure, the area is covered
o To alleviate this problem, an escharotomy (cut a fellow nurse as the hurter or “bad guy.” It helps by a bulky dressing. So that the growth of the
into the eschar) is performed. Some bleeding will if people alternate this chore so that, on newly adhering cells will not be disrupted, this
occur after escharotomy. Packing the wound and alternate days, each serves as the protector or should not be removed or changed.
applying pressure usually relieves this. the comforter. o The donor site on the child’s body (often the
o If eschar tissue is débrided in this manner day anterior thigh or buttocks) is also covered by a
 Débridement after day, granulation tissue forms underneath. gauze dressing. Both donor and graft dressings
o It is the removal of necrotic tissue from a burned When a full bed of granulation tissue is present should be observed for fluid drainage and odor.
area. Débridement reduces the possibility of (about 2 weeks after the injury), the area is ready o Observe the child to determine whether there is
infection, because it reduces the amount of dead for skin grafting. In some burn centers, this pain at either site, which might indicate infection.
tissue present on which microorganisms could waiting period is avoided by immediate surgical o Monitor the child’s temperature every 4 hours. A
thrive. excision of eschar and placement of skin grafts. rise in systemic temperature may be the first

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indication that there is infection at the graft or

donor site.
o Autograft sites can be reused every 7 to 10 days,
so any one site can provide a great deal of skin
for grafting.

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