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Accidental Injuries: A Pediatric Concern

1.5 Contact Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Midwife (MW), Nursing Student, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Saturday, January 24, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.



FPTA Approval: CE24-1159046. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

≥ 92% of participants will have a better understanding of the mechanism for childhood injury, associated risk factors, nursing care, and anticipatory guidance for injury prevention.

Objectives

After completing this continuing education course, the participant will be able to:

  1. State why accidental injuries are a pediatric health concern.
  2. List the risk factors for accidental injury based on age, gender, race, and other variables.
  3. Determine the appropriate anticipatory guidance for the prevention of childhood injury and death by suffocation, strangulation, and choking.
  4. Differentiate the risks of drowning based on a child’s age.
  5. Identify the age-appropriate anticipatory guidance for motor vehicle safety.
  6. Describe the various mechanisms of injury that lead to falls, based on age.
  7. Examine the spectrum of care utilized in poisonings and how to determine what treatment a child needs.
  8. Explain how to determine the stage and surface area percentage of a burn.
  9. Recognize the risk factors for firearm injury in children with guns in their home.
  10. Explain the risks of social media usage.
  11. Identify the red flags for when an injury may be intentional or abuse rather than accidental.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Accidental Injuries: A Pediatric Concern
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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Sarah Schulze (MSN, APRN, CPNP)

Introduction

For centuries, childhood deaths were most often related to diseases that spread quickly through unsanitary conditions and contaminated drinking water. Lack of treatment, or even understanding, of viral and bacterial infections led to serious and often fatal complications among children, often before their fifth birthdays. Now, in the era of readily available vaccines, clean drinking water, and proper understanding of handwashing and how pathogens are spread, death from communicable disease, while still possible, is no longer a major risk for children and the focus has shifted to another health concern: accidental injuries.

For many decades now, the leading cause of death in all children from birth through the teen years is accidental injury. In 2019, more than 7,000 children died in the United States because of an accidental or unintended injury (Centers for Disease Control and Prevention [CDC], 2021). These injuries include accidents such as car crashes, drowning, suffocation, falls, poisoning, and fires, among many others. Awareness of accidental injury in children is particularly important because they are oftentimes preventable with simple education and safety measures for families.

This course aims to familiarize healthcare workers with the most common types of childhood injuries, who are most at risk, care implications for children who have sustained these injuries, and anticipatory guidance and safety measures for families. Healthcare workers, particularly those who work with children and families, are in a unique position to provide education about safety and prevention measures, reducing the incidence of these devastating and often fatal injuries and helping children reach adulthood unharmed.

Epidemiology of Accidental Injuries in Children

Each day in the United States, about 20 children die from an unintended injury. Worldwide, accidental injuries are responsible for the deaths of just under 1 million children annually (World Health Organization [WHO], 2008). Awareness, legislation, and safety measures have made an impact on this issue, with injury death rates in the United States decreasing around 11% since 2010, however accidental injuries still remain the leading cause of death in all age groups for children and teens (CDC, 2021).

The type of injury most often responsible for death varies by age group (CDC, 2021):

  • Suffocation is most common among infants < 1 year
  • Drowning is most common among children ages 1-4 years
  • Motor vehicle crash injuries are most common among ages 4-19

The risk of unintended injury varies across demographics as well, with certain populations being more at risk. From 2018-2019, risk was highest among (CDC, 2021):

  • Male children
  • Children either under 1 year of age or between 15-19 years
  • American Indian, Alaskan Native, and Black children
  • Children living in rural locations

Like many other areas of healthcare, the disparities among minority races are being highlighted and studied further to understand the societal and individual biases that may be impacting these inconsistencies and where changes can be made to promote equity. It is important to note that while the overall rate of accidental injuries in children has decreased in recent years, certain populations have actually experienced an increase since 2010, including the data below (CDC, 2021):

  • A 50% increase in poisoning and drug overdose in Hispanic children and 37% increase in poisoning and drug overdose in Black children
    • Poisoning and overdoses in white children decreased by 24% during the same time period
  • A 20% increase in suffocation among all infants < 1 year, with a 21% increase in suffocation among Black children
  • A 9% increase in motor vehicle deaths in Black children
  • Drowning rates are 2.6 times higher than white peers among Black children that are 5-9 years old and 3.6 times higher among Black children that are 10-14 years old

Not all accidental injuries result in death. In fact, around 9.2 million children annually are seen in emergency rooms across the country for accidental injuries. The most common types of nonfatal injury again varies by age (CDC, 2008):

  • Falls were the most common injury among all age groups
  • For ages 0-9 years, the next 2 most common nonfatal injuries were being struck by an object and animal bites
  • For ages 10-14, the next 2 most common nonfatal injuries were being struck by an object and overexertion
  • For ages 15-19, the next 2 most common nonfatal injuries were being struck by an object and motor vehicle accidents

Whether or not an injury was fatal also varied greatly by age (CDC, 2008):

  • Poisonings were fatal 5 times more often for children over the age of 15 compared to younger groups
  • Suffocation was fatal 16 times more often for children under age 1 compared to older children

Gender also affected rates of nonfatal injury. For children ages 1-19 years, the rate of all nonfatal injuries was higher among males. For children under age 1, the rate of nonfatal injuries was the same among males and females (CDC, 2008).

Understanding how risk varies across age, gender, and race can help healthcare workers better understand how to identify those most at risk and implement strategies to improve safety for all families.

Types of Injuries, Nursing Care, & Prevention

Suffocation, Strangulation, & Choking

Suffocation can occur to children of any age, but it is most common in children under 12 months of age. In fact, suffocation is responsible for 87% of fatal injuries in children under the age of 1 (Gao et al., 2018). In 2019, there were 1,243 deaths related to suffocation in children ages 0-5. Suffocation in infants is most often linked to unsafe sleep practices, such as sleeping on unapproved surfaces with bumpers, soft and loose bedding, or other people (Safe Kids Worldwide, 2022).

While the majority of suffocation deaths occur with unsafe sleeping practices, around 20% occur from other causes such as playing with plastic bags or in small, unventilated spaces. Toddlers and preschoolers, ages 1-5, are more mobile and may get into risky situations without the ability to get out (Safe Kids Worldwide, 2022).

Not all suffocation results in death. In 2019, there were 16,372 emergency room visits and 1,985 hospitalizations related to suffocation injuries in children under 5 (Safe Kids Worldwide, 2022).

Strangulation is also a risk to young children, usually from blind cords, drapery, entrapment between cribs and other furniture, or clothing such as drawstrings, necklaces, or scarves. Items around the neck may be caught in car doors, playground equipment, or other objects (Children’s Hospital of Philadelphia [CHOP], n.d.).

Choking is also a risk for children, particularly those under the age of 5 due to the smaller size of the airway. Food accounts for about 50% of childhood choking, with large, round, or hard foods becoming lodged. Other non-food items such as coins, buttons, marbles, balloons, magnets, pet food, batteries, or pieces of toys account for the other 50% (Healthychildren.org, 2019).

Nursing Care

All of these accidents have a shared mechanism of injury in that they restrict breathing and oxygen perfusion to the brain and other organs and tissues, known as asphyxia. Children who are non-fatally injured may have varying levels of brain damage resulting from hypoxia. Mechanical ventilation may be necessary as well as EEG monitoring to assess brain function or seizure activity. The severity of injury, and resulting sequelae and disability, is closely related to the amount of time a child was hypoxic before the breathing obstruction was removed. Children who have experienced strangulation will likely have a characteristic ligature mark, or pressure marking, on the neck (Kumar et al., 2011).

Anticipatory Guidance

Preventing injury or death from asphyxia centers around:

  • Safe sleep practices
  • Careful food preparation
  • Age-appropriate childproofing of the home
  • Close supervision of young children 

All children under 12 months of age should sleep on their backs (until they can roll on their own) on a firm mattress without pillows, blankets, or stuffed animals. Crib bumpers and reclined infant sleepers (such as Rock-’n-Plays) have been recalled due to increased suffocation risk and occurrence of infant deaths. Bed Sharing with an infant, particularly if a parent is under the influence of drugs or alcohol, is advised against (CHOP, n.d.).

When infants begin eating solid foods, choices should be soft or easily mashed and cut into bite sized pieces. Items such as whole grapes, hot dogs, popcorn, nuts or seeds, and large pieces of raw vegetables should be avoided until age 4 when the airway is larger and children have molars to assist with chewing harder foods (Healthychildren.org, 2019).

Childproofing the home for infants includes removing or tying blind cords out of reach, keeping large items like dressers and bookshelves at least 2 feet away from the crib, keeping small items and toys off the floor and out of reach, and avoiding teething necklaces or pacifiers that go around a child's neck. The Child Safety Protection Act bans the sale of any toys that pose a choking risk and are intended for children under the age of 3. Toys that have small parts or are a choking risk must be labeled as for children > 3 years (CHOP, n.d.).

Drowning

For children ages 1-4, drowning is the number one fatal injury that occurs. For older children, it is the second leading cause of death after motor vehicle accidents. The location of drownings varies by age:

  • < 12 months: Bathtubs
  • Ages 1-4: Home swimming pools
  • Ages 5-14: 40% in natural bodies of water (river, lakes, streams), 30% in swimming pools
  • Ages 14+: > 50% in natural bodies of water

Not knowing how to swim, poor supervision, lack of proper fencing around pools, and not wearing life jackets are among the risk factors for drowning. Nearly 80% of drowning deaths occur in boys. Black pre-teens are over 7 times more likely to die from drowning than white peers. Seizure disorders and certain heart conditions like Long QT syndrome also significantly increase the risk of drowning. For adolescents, alcohol use paired with water recreation significantly increases the risk of injury and death. Nearly 70% of adolescent drownings involve alcohol. The U.S. Coast Guard also reported that in 2021, of the 658 boating-related deaths (of any age), 83% of those fatally injured were not wearing life jackets (CDC, 2022b).

Nursing Care

Drowning does not always result in death. For every child who dies from drowning, there are 7 children who experience non-fatal drowning.

Drowning has a very high rate of hospitalizations and complications, with 40% of emergency room visits requiring hospitalization (compared to 10% of other types of injury) (CDC, 2022b). Drowning causes impaired oxygenation to the brain and other organs, leading to possible brain damage and permanent disability. Most children who drown experience either cardiac arrest or respiratory arrest and require resuscitation. Multiple Organ Dysfunction Syndrome (MODS) occurs in the majority of cases with the respiratory, neurologic, cardiovascular, gastrointestinal, hematologic, and renal complications being the most common, in that order of occurrence (Mtaweh et al., 2015).

Mechanical ventilation following drowning is common. Nurses can also expect EEGs to monitor brain function, risk of additional arrests requiring resuscitation, and sometimes even the need for dialysis (Mtaweh et al., 2015).

Anticipatory Guidance

The best ways to prevent drownings include formal swimming lessons for children, fencing or restricted access to pools or bodies of water, use of life jackets, avoidance of drugs or alcohol while near water, and close supervision at all times when children are in or near water. It is recommended that when children are swimming, there is at least one adult dedicated to watching the pool or body of water at all times so as to avoid distracted adults for even a minute. Even among children who know how to swim, they should be counseled to never swim alone and always have someone with them before entering a pool or body of water (CDC, 2022b).

Motor Vehicle Accidents

The most common type of injury overall among children is motor vehicle accidents (MVAs). In 2020 alone, 63,000 children under 12 were injured in motor vehicle accidents and 607 died. Of those fatally injured, 38% were not buckled. Studies show that car seat and seat belt compliance decreases as children age (CDC, 2022a). A 2019 observational study of restraint usage found that (CDC, 2022a):

  • 3% of children under 12 months were not buckled
  • 6% of children ages 1-3 were not buckled
  • 14% of children ages 4-7 were not buckled
  • 13% of children 8-12 were not buckled

This statistic of decreased restraint usage as children age is mirrored in 2020 data surrounding MVA fatalities as well (CDC, 2022a):

  • 31% of fatally injured children < 4 years and younger were not buckled
  • 40% of fatally injured 8–12-year-olds were not buckled

Child fatality rates in MVAs were around 4 times higher in rural areas compared to urban areas. The highest rate of MVA fatalities by race is among American Indian and Alaskan Native, followed closely by Black children. Other risks for MVA deaths include alcohol impaired driving; 24% of child deaths in MVAs involved an alcohol impaired driver and more than half of drunk drivers failed to restrain the children riding with them. Unbuckled drivers also result in higher incidence of unbuckled children. Even when children are buckled, car seat and booster seat misuse increases the risk of serious injury or death when riding in a vehicle. It is estimated that 46% of car and booster seats are used improperly, including (CDC, 2022a):

  • Incorrect recline angle
  • Loose installation of car seat
  • Loose harness
  • Part of harness or straps behind child
  • Improper lap belt position for booster seats
  • Improper shoulder belt position for booster seats

For teens ages 13-19, around 2,800 die annually in MVAs, the leading cause of death for this age group. Teen drivers ages 16-19 have a death rate 3 times higher than older drivers involved in MVAs. Inexperience plays a huge role in this, and the risk of death is highest during the first few months of learning to drive. Nighttime driving risk is also higher for this age group. Other risk factors include distracted driving, drowsy driving, reckless driving, impaired driving, not using a seatbelt, and having teenage passengers in the car with the young driver (as this increases distraction, recklessness, or impaired driving) (CDC, 2022c).

Nursing Care

Children involved in MVAs can have a wide variety of injuries, including head and neck injuries, internal organ damage or bleeding, broken or dislocated bones, severe bruising, lacerations, and more. Care should be prioritized to maintain an airway and stop any bleeding. Imaging is often useful to assess for internal bleeding or broken bones and close monitoring to assess for changes in level of consciousness is important.

Some children, particularly those who were buckled, may only sustain mild injuries and may not require hospitalization or higher-level care. Others may be more seriously injured, especially if they were not buckled or were thrown from the vehicle and may need hospitalization, surgery, mechanical ventilation, or other treatments.

Anticipatory Guidance

Proper restraint usage is the number one way to reduce MVA injury and deaths in children of any age. Child restraint laws as well as car and booster seat provisions have decreased the rates of MVA injuries and deaths over the years and education about proper car and booster seat usage is an extremely important topic for healthcare professionals to cover. Information about proper car seat usage, when children should be rear-facing and forward-facing, car seat angles, and how to properly buckle and position harnesses could quite literally save a life (CDC, 2022a):

  • Rear-facing car seat: Children should be in a rear-facing seat with a harness from birth until age 2-4 years. Children should remain in the seat until they reach the maximum weight or height as indicated by the manufacturer. Children this age should never be in the front seat of a vehicle.
  • Forward-facing car seat: Children should be in a forward-facing car seat with a harness after outgrowing a rear-facing car seat until at least age 5. They should remain in the seat with a harness until they reach the maximum weight or height of the seat. Children should not be in the front of a vehicle when in a forward-facing car seat.
  • Booster seat: Once children outgrow the forward-facing car seat, they should be in a high-backed booster seat until age 9-12 when the seat belt fits properly without a booster seat. Children should still be in the back seat in a booster seat.
  • Seat belt: When a seat belt fits properly with the lap belt across the thighs and the shoulder belt is across the chest and shoulder (not the child’s neck/face or off the shoulder), then a child may use just a seatbelt. They should remain in the back seat until age 12.

Help with car seat installation is available in most areas, often through a local police station. Children under 12 should also be in the back seat rather than the front as airbags can cause serious injury in younger children (CDC, 2022a).

For parents of teen drivers, practicing as much as possible, during different times of day and driving conditions, is very important. Parents and healthcare workers should have conversations with teens about the risks of impaired or reckless driving as well as the importance of wearing a seatbelt. It is recommended to have teens off the road by 10:00 pm and to avoid allowing them to drive teenage passengers for at least the first 6 months once they get a license (CDC, 2022c).

Falls

Falls are the leading cause of all non-fatal injuries in children birth to 18 years. Nearly 3 million fall-related emergency room visits for children occur annually nationwide, with about 1.2 million of those being for children under 5 years (State of Rhode Island Department of Health, n.d.).

Falls can cause a variety of injuries, from simple bruises and abrasions, to broken bones, and head injuries. Head injuries account for the most severe injuries and fall-related deaths, most often in children under 5, whose heads are larger and may take the impact of the fall first (State of Rhode Island Department of Health, n.d.).

The cause and types of falls vary by age. Infants and toddlers are learning to crawl, stand, climb, and walk and anything can pose a risk to them. They may fall off of changing tables, couches, highchairs, stairs, or beds or even be dropped by caregivers. While the use of baby walkers is cautioned against, many people still use them, and babies may accidentally fall downstairs or steps while in them.

Older children may fall off of playground equipment, bunk beds, from trees, windows, or objects they have climbed. Teens may engage in risky behavior of climbing even higher objects such as roofs, buildings, ladders, or other dangerous places (State of Rhode Island Department of Health, n.d.).

The height of a fall and the way a child lands have a lot to do with the type and severity of injury incurred. Falls from higher up cause more damage and falls where the head is hit first are more likely to be severe. Young children are more likely to experience injury to the face and head, while older children experience hand and arm injuries more often. Boys are twice as likely to die from fall-related injuries than girls (Stanford Medicine, n.d.a.).

Nursing Care

Potential injuries from falls include fractures (often of the femur, humerus, or skull), intracranial hemorrhage, and concussion.

Nursing care for fractures includes managing pain and swelling. Rest, ice, compression, elevation (RICE) as well as medications like acetaminophen and ibuprofen are useful. Imaging is commonly needed.

For head injuries, monitoring neurologic status is standard. Symptoms such as vomiting, change in coordination, speech, or level of consciousness, or asymmetric or nonreactive pupils can indicate serious head injury or intracranial hemorrhage. Imaging and hospital admission may be needed for more serious head injuries.

Anticipatory Guidance

Close supervision and childproofing of the house are necessary to prevent falls (State of Rhode Island Department of Health, n.d.):

  • Infants should not be left alone on beds, couches, changing tables, or other furniture
  • Infants should sleep in a safe, age-appropriate bed
  • Move a child from a crib to a bed when they are attempting to climb out or the rail is at less than ¾ their height
  • A safety rail should be used when transitioning from a crib to toddler bed
  • Always strap a child into their highchair
  • Use safety gates at the top and bottom of stairs
  • Avoid using baby walkers with wheels
  • Keep windows locked when not in use
  • Supervise children around windows and do not rely on screens to prevent falls
  • Install window guards
  • Move furniture a child could climb on away from windows
  • Supervise children when climbing on playground equipment
  • Encourage and model proper helmet usage when riding a bike
  • Advise teens of the dangers of climbing and jumping off of tall objects

Poisoning & Overdose

More than 1 million calls are made to poison control about accidental ingestion of poisonings annually, the majority occurring in children under the age of 5. Potential poisons come from a wide range of common household products; from medications, alcohol, cleaning supplies, cosmetics, plants, paint, and vapors (such as carbon monoxide). Over 90% of all reported poisonings occur in a child’s own home, with the majority of calls between 4:00 pm and 10:00 pm, during the hectic after work/dinner time/bedtime rush (Stanford Medicine, n.d.c.).

While there is a large list of potential products children accidentally ingest, medications are the most common culprits. Medication errors occur when children are given a medicine at the wrong time, the wrong amount, or that was measured incorrectly. Children may also get into medication that is not even prescribed for them and will often put anything they find into their mouths (Stanford Medicine, n.d.c.).

Nursing Care

Treatment of children who are poisoned depends largely on the substance ingested and the amount, as well as any symptoms the child is experiencing. Poison Control is a wonderful resource that can be used by anyone, including parents at home. Healthcare professionals can also contact them to consult about particular substances and symptoms to watch for as well as best action for treatment (Nemours Kids Health, 2022).

Often, nothing more than close observation is needed as long as children are acting normally. However, in the case of very toxic substances or large amounts ingested, children may need more aggressive treatment. Signs that treatment may be needed include drowsiness, heavy drooling, difficulty breathing, vomiting, and confusion (Nemours Kids Health, 2022).

Toxicology testing may be used to identify certain poisons and additional labs can be used to monitor liver and kidney function. Many potential toxins can be treated with antidotes such as activated charcoal, naloxone, sodium bicarbonate, and various antibodies or vitamins. If airway or breathing is affected, supplemental oxygen or even mechanical ventilation may be needed while the poison is cleared (Buckley et al., 2016).

Anticipatory Guidance

Guidance to prevent poisoning relies heavily on childproofing the house as curious children will often ingest whatever they find (Stanford Medicine, n.d.c.):

  • Keep medications in childproof containers and locked up
  • Keep cleaning products and alcohol out of reach and locked up
  • Discard used batteries safely. Keep new batteries out of reach
  • Do not call medicine candy when giving it to children
  • Do not repurpose old food/drink containers for holding cleaning products
  • Do not put poison for rodents or insects out on the floor
  • Teach all parents/caregivers about how to contact Poison Control and have the number readily available in the home

The Poison Control emergency number, for anywhere in the United States, that is accessible 24 hours a day, 7 days a week, 365 days a year is: 1-800-222-1222.

Fires & Burns

Fires and burns are the 5th most common type of accidental injury causing death. There are 4 main types of burns, including (Stanford Medicine, n.d.b.):

  • Thermal burns: From external heat sources that char the skin and tissues. Scalding liquids, hot metals, steam, and flames.
  • Radiation burns: From prolonged exposure to UV light or X-ray.
  • Chemical burns: From strong acids, detergents, or solvents on the skin or eyes.
  • Electrical burns: From electrical current.

Scald burns are among the most common of all burns, with hot tap water being a common and preventable cause. The ways in which children are burned varies by age (Johns Hopkins Medicine, n.d.):

  • 0-5 years:
    • Flames: Most commonly encountered when playing with matches, lighters, firepits, and fireplaces.
    • Scald: Most commonly occurs by pulling pots/pans off of the stove or getting into sink or bathtub water, unsupervised, that is too hot. 65% of children this age hospitalized for burns are related to scaldings.
  • 5-10 years:
    • Flames: Occurs when playing with fire or engaging in risk-taking behaviors. Males more commonly affected.
    • Scald: Most commonly occurs in the kitchen or bathroom. Females more commonly affected.
  • 10+ years:
    • Flames: Most often encountered with risk-taking behaviors with peers, including use of gasoline or fireworks.
    • Electrical: Occurs through risk-taking behaviors like climbing utility poles.

Nursing Care

Burn care is a specialized area of nursing and requires frequent and close monitoring for pain management, infection prevention, and optimal healing. Pain management is one of the most important aspects of burn care, but also the most difficult. Burns may be extremely painful, particularly when they affect a large surface area of the skin. Burn severity is measured in the surface area affected and depth of the burn. For surface area calculation, the Rule of Nines is typically used (Moore et al., 2022):

  • Head/neck = 9% anterior, 9% posterior (total of 18%)
  • Each arm/hand = 4.5% anterior, 4.5% posterior (total of 9% per arm)
  • Torso = 18% anterior, 18% posterior (total of 36%)
  • Each leg/foot = 7% anterior, 7% posterior (total of 14% each leg)

The standard Rule of Nines used for adults can be modified slightly depending on the age and size of the child. An adapted chart is included below (Moore et al., 2022).

Image #1: Pediatric Adaptation of Rule of Nines

Graphic showing pediatric adaptation of rule of nines

(Image adapted from Moore et al., 2022: Figure contributed to article by Rian Kabir, MD; Based on research by the Burn and Reconstructive Centers of America [BRCA], 2022)

Burn severity is also measured in the thickness or staging, or the amount of tissue affected by the burn (Stanford Medicine, n.d.b.):

  1. First degree burns: Affect only the outer layer of skin, the epidermis. Burns are red, dry, and painful.
  2. Second degree burns: These partial thickness burns affect the epidermis and part of the dermis. They are red, painful, and blistered.
  3. Third degree burns: Full thickness burns that destroy the epidermis and dermis. They may also affect the tissue underneath including muscle and bone. The burn site is white or charred. Nerves are destroyed so there is no sensation to the area.

Nursing care also focuses on fluid and electrolyte balance as “third-spacing” or burn edema is common with large fluid and protein shifts following thermal injury. With the loss of tissues to burns, there is less oncotic pressure on blood vessels and vascular permeability suddenly increases, with fluid literally leaking out into the surrounding and damaged tissues.

Nursing care also involves protection and restoration of skin integrity. Wound debridement, skin grafts, and burn cream application are among the possible treatments of burns. Keeping the area clean is very important as infection to large surface area or full thickness burns can result in severe infection, including osteomyelitis, sepsis, gangrene, and even the need for limb amputation.

Coordination of a complex care team is an important nursing function. Burn victims will often have plastic surgeons, orthopedics, infection specialists, physical therapists, and occupational therapists among others as they recover (Stanford Medicine, n.d.b.).

Anticipatory Guidance

Prevention of burns includes (Johns Hopkins Medicine, n.d.):

  • Use and maintenance of smoke detectors
  • Reducing smoking around children
  • Keeping lighters, matches, candles, and other flames out of reach of children
  • Keeping hot water heater temperatures at 120 degrees Fahrenheit or lower
  • Do not bring children around open fires like bonfires
  • Keep boiling or hot liquids on the back burners of the stove top
  • Educate adolescents about the dangers of burns and discourage play with flames or fireworks

Firearms

Guns are a huge safety issue in the United States and a hot topic in children’s health, with firearm injuries rising to the leading cause of accidental death in children 0-18 years over the last few years. Nearly 1,300 children die by injuries from firearms annually and it is estimated that 1 in 3 families with children have a gun in the house, therefore firearm safety is paramount. While public, school, and mass-shootings are their own risk and crisis in this country, the safety issues with guns for this course will center on unintentional injury/accidental shooting in children’s homes (Nationwide Children’s, n.d.).

Almost 40% of unintentional shooting injuries in children ages 11-14 years occur in a friend’s home. Children unintentionally shot are most often boys and are most often shot by a friend or relative. Improper storage of guns in the home is one of the main reasons these injuries occur.Parents may erroneously believe that keeping guns hidden or teaching children not to touch guns if they find them is enough, but studies show this is not the case and most children will pick up and handle a gun if they find one, regardless of parental teaching. It is also a common but dangerous myth that children are not old enough to fire a gun, in fact children as young as 3 have been able to pull the trigger on improperly stored guns. Even guns like BB guns and paintball guns are dangerous if improperly handled. These guns account for 22,000 injuries annually, most often injuries of the eyes (Nationwide Children’s, n.d.).

Nursing Care

Nursing care depends largely on the type of injury sustained. Minimizing blood loss is of high priority with any shooting injury. Replacing excessive blood loss with transfusions may be needed. Surgery may be needed to remove bullets or shrapnel or to salvage limbs or repair wounds.

For children with severe gunshot wounds, mechanical ventilation may be necessary, and EEGs may be used to assess brain function if children were shot in the head or are unresponsive. For children who survive a gunshot, permanent disability or disfigurement may occur.

Anticipatory Guidance

Gun safety is a topic all healthcare professionals should take seriously when they work with children. The best way to keep children safe from firearm injuries is to not have guns in the house at all. If this is not possible or not desired, then measures must be taken to maximize safety (Nationwide Children’s, n.d.):

  • Guns should be stored unloaded, and ammunition kept in a separate place
  • Both guns and ammunition should be locked up in a lockbox or gun safe
  • Storage keys or lock combination should be hidden from children and not easily found in common areas
  • Ask friends or relatives about gun safety before leaving children alone at other houses
  • Do not leave children unattended in homes with guns

Social Media Challenges

A relatively new cause of injury and even death among children, particularly teens, are social media challenges, largely found on TikTok. These virtual dares often go viral and challenge teens to complete a dangerous or risky task while friends film it, so the video can be posted and added to a compilation of other teens completing the challenge.

Underdeveloped teenage brains are often impulsive enough to engage in such activities without a full understanding of potential consequences. The draw of attention via social media is often too great for them to resist, putting them at increased risk of injury (Healthychildren.org, 2022). Examples of such challenges include:

  • Blackout Challenge: Participants hold their breath until they pass out. At least 15 children under the age of 12 have died from participating in this challenge.
  • Cinnamon Challenge: Participants attempt to swallow a spoonful of cinnamon which is naturally hydrophobic and cannot be swallowed in large quantities. The powder can be easily inhaled, causing coughing, choking, and aspiration.
  • Nyquil® Challenge: Participants cook chicken in a marinade of Nyquil or other cough and cold medicine and then consume it.
  • Benadryl® Challenge: Participants are encouraged to take large doses of Benadryl® to see if they hallucinate.
  • Salt and Ice Challenge: Participants apply salt to bare skin and then place an ice cube over it for as long as they can tolerate. The salt lowers the freezing temperature of the ice and may cause frostbite or severe skin damage.
  • Milk Crate Challenge: Participants stack milk crates and then climb them like stairs to see how high they can get before the unstable crates collapse.

There are many other challenges, and they seem to come and go from popularity at a rapid rate.

Nursing Care

Nursing care for children and teens injured from social media challenges can vary just as much as the details of the challenges themselves. Head injuries, broken bones, burns, poisoning, hypoxia, asphyxia, and overdose are among the potential injuries and may be mild or severe, requiring a wide variety of care measures (Healthchildren.org, 2022).

Anticipatory Guidance

Frequent conversations about safe social media usage are necessary from parents and healthcare professionals alike. Parents should set positive examples for social media usage as well as have safe boundaries and frequent monitoring of their child’s social media and internet usage. Talking about the potential dangers of social media challenges as well as the consequences of these challenges is important as well (Healthchildren.org, 2022).

Differentiating Accidental Injury From Abuse

While accidental injuries in children are extremely common and are most often completely unintentional, it is important for healthcare professionals to remain alert to signs of abuse or intentional injury so that abuse can be identified, and children can be removed from harmful situations as quickly as possible. While laws vary by state, all healthcare professionals are considered mandated reporters in some capacity and have a responsibility to report suspicious cases for further investigation (Pressel, 2000).

There are particular red flags that need to be approached with a high level of suspicion for abuse (Pressel, 2000):

  • A history that is inconsistent with the child’s injuries or inconsistent among caregivers (the story seems implausible, or it keeps changing)
  • Failure to report an injury in a timely manner
  • Bruises or fractures in infants who are not yet mobile
  • Bruises over areas not typical with accidental injuries
    • Common areas for children to be bruised are over bony prominences (knees, shins, elbows, etc.)
    • Areas suspicious for abuse include over soft tissue (abdomen, back, neck, etc.)
  • Patterned bruises in the shape of household objects or handprints
  • Circumferential bruises or burns
  • Multiple injuries in different stages of healing
  • Spiral fractures without a history that implies twisting or getting caught on something
  • Retinal hemorrhages

Healthcare providers do not have to have proof that abuse occurred, they only need to identify that a scenario has red flags or is suspicious for abuse. In the event an injury is reported, Child Protective Services (CPS) assumes the responsibility to evaluate the reported injury as well as visit the home or place where the injury occurred in order to assess for congruency in the story and plausibility of the injury truly being accidental.

Case Study

Scenario

A 4-year-old child, William, is brought to the emergency department by helicopter after being life-flighted from the scene of a drowning. The child was attending a birthday party and all of the children and adults had exited the pool to have cake. William had slipped away unnoticed to get back into the ungated pool but did not have his flotation device on. An adult at the party noticed him bobbing in the water and immediately pulled William from the pool where he was found to be unresponsive and without respirations or a heartbeat. CPR was started at the scene while another parent called 911. It is unknown how long William was in the water before being pulled out, but parents at the scene estimated no more than 2 minutes.

Intervention

While in the helicopter, resuscitation efforts were successful, and William’s heartbeat and respirations returned. He was placed on supplemental oxygen but did not need intubation or mechanical ventilation. He was admitted to the hospital for observation for repeated cardiovascular arrests, subsequent multiple organ dysfunction syndrome (MODS), pneumonia, or other complications.

After 36 hours, the supplemental oxygen was discontinued, and he was doing well with no obvious neurological deficits. He was discharged home after just 4 days in the hospital.

Discussion

Water safety is of the utmost importance for William’s age group as drowning is the #1 cause of fatal injury in children ages 1-4. The risk factors were increased in this scenario because it was a crowded event with many children and distracted adults. The pool was not gated, so even if there was an adult appointed to pool supervision while the children were swimming, the pool was no longer supervised but still easily accessible when all the children got out. The story is plausible and consistent with the injury as well as the reports of multiple adults present, so no suspicion of abuse is present.

Strengths

The quick action of the adult who pulled him out and began CPR is likely what saved his life. Minimizing time underwater and immediate resuscitation efforts increase the chance of survival. Even though he was breathing and stable in the ED, the risk of repeated arrest and development of MODS is high in the first 24 hours after a drowning, so admitting William for continued observation was a necessary and correct choice.

Weaknesses

While the family is likely experiencing significant trauma after such an event, it is an excellent opportunity to provide education about water safety. It is unknown how much anticipatory guidance was given to this family by their regular pediatrician prior to this incident, but additional information about gating off pools, supervision of children when they are within the pool area, and swimming lessons should be provided to this family.

Conclusion

Unintentional injuries are front and center for children’s health concerns, causing millions of emergency room visits and thousands of deaths annually. Healthcare professionals who work with children have a responsibility to educate families about the risks and most common types of injuries. Anticipatory guidance about how to protect, supervise, and keep children safe could very well save lives and should be discussed at every opportunity. Familiarity with these issues can help reduce the number of accidental injuries, their complications, and deaths each year.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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