Accidental Injuries: A Pediatric Concern

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).

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 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).

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).

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.

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).

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.

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

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).

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.

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

(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.).

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

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.

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

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).

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).