PAEDIATRIC

EMERGENCIESBURNS HEMORRHAGEFOREIGN BODIES ASPIRATIONPOISONINGDROWNINGFALL - FRACTURE

BURNS

• Burn injuries caused by extreme heat sources but may also result from exposure to cold, chemicals, electricity, or radiation.

Incidence

• Approximately 1/4th of cases are below 10 yrs of age.

• About 65% of burnt children are <5yrs of age.• >80% of burn accidents occurs in the child’s

own home.• Scalds from hot liquids constitute maximum

numbers than others(flame, electrical, chemical).

• Incidence increased in diwali festival & winter season.

ETIOLOGY• Scald injury from moist heat : kitchen or

bathroom – (water at 68oC / 156oF can cause 3rd degree burn in one second.

• Flame injury : faulty

electrical wiring, cigarettes,

kerosene stove, gas stove,

cloths catches fire, crackers.

• Electrical injury : inserting

conductive objects into electrical outlets, bite or suck in electrical cords.

Causes contd..

• Chemical injury and contact injury : handling or ingestion of caustic household agents.

• Radiation injury : overexposure to ultra violet rays from the sun

Radiation burn

The effect of burns …• Circulating plasma volume loss →decrese cardiac output (by 36

hrs. of burn).

• Hypovolemia → diminished renal perfusion → reduced GFR→renal failure.

• Water, electrolyte, albumin & protein extravate into interstitial & intracellular compartments, forming edema.

• Decrease perfusion in peripheral tissue, metabolic acidosis, hypotension.

• Polycythemia due to hemoconcentration

• Increase blood viscosity leading to slugging in the vasculature.

• Acute gastric dilation→abdominal distension→ regurgitation; decrease blood supply→decrease motility→malabsorption; gastric ulceration.

Clinical manifestations• Body surface area burnt

• Shock (pallor, cyanosis, poor muscle tone, rapid pulse, hypotension, subnormal temp.)

• Inhalation cases – inflammation /edema of airway → obstruction of airway ( dyspnea, tachypnea, hoarseness, stridor, chest retractions, nasal flaring, restlessness, cough, drooling)

• Pulm. Edema, spasm leads to severe airway obstruction, bronchiolitis

• Toxemia- fever, vomiting, ededma, oliguria, tachycardia, glycosuria, unconsciousness

Classification According to depth of burn injury :• Superficial (partial thickness) –

- Superficial partial thickness

- Superficial deep thickness

• Full thickness

According to event of burn injury :• 1st degree

• 2nd degree

• 3rd degree

According to severity :• Minor

• Major

Estimation of depth of burn injury

• First degree : affecting the epidermal layer is characterized by erythema due to vascular response, edema occurs in the basal layer irritating the nerve ending & causing discomfort.

• Second degree : subdivided into superficial partial & deep partial thickness burns.

-- In superficial partial thickness – the surface may be covered with blisters, the skin beneath it is glistening bright pink & red, sensitive to touch, temp. & airflow.

-- Deep partial thickness –destroys entire thickness of epidermis.

• Third degree : full thickness burns involves all epidermis & dermis. The burnt skin is hard & dry, tan or fawn colored. Higher morbidity.

4th degree

Classification --• Minor – 1st degree, 2nd degree of <10% of

body surface area, 3rd degree <2% of BSA.

• Moderate – 2nd degree with 10-25% of BSA, 3rd degree <10% of BSA (except face, hand & feet).

• Major – 2nd degree >25% of BSA or 3rd degree over face, hand or feet or/ > 10% of BSA.

Estimation of burn area

• Rule of hand : one hand surface(child’s own hand) with closed fingers amounts to 1% of body surface area.

• Rule of nines : first described by Pulaski & Tennison & popularized by Wallace; applicable only to children >10yrs of age & adults.

*Leg= 13.5 each leg

*Head front

& back=18%

Adult & *children

Rule of five – Lynch & Blocker, 1963

Area Age 0-5 yrs. Age 5-10 yrs. Age 10 yrs. & avove

Head & neck 20% 15% 10%

Trunk frontTrunk backUpper limbsLower limbs

20%20%10X2=20%10X2=20%

100%

20%20%10X2=20%15X2=30%

105%(105-5= 100%)[to be deducted from trunk]

20%20%10X2=20%15X2=30%

100%

EMERGENCY FIRST AID• Immediate removal from heat source

• Stop, drop, and roll……

• Stopping the burning process

• Cool water should be poured on flamed area

• Protection of burn area

• Prevention of hypothermia (wrap with clean sheet)

• Observation of ABC

• Transportation to a medical facility

• Lavage for chemical (ingestion) burn for 10 minutes

• Emotional support of family members

IMMEDIATE MANAGEMENT

MINOR BURN INJURY

• History & Assessment

• Fluid management

• Cleansing .

• Debridement.

• Application of sterile protective dressing.

• Tetanus immunoglobulin are administered.

• Patient should return to the OPD every 48hrs for redressing.

• Antibiotic therapy

MAJOR BURN INJURY• A complete trauma assessment.

• Assess for Airway ,Breathing and Circulation.

• Initiate CPR as an indication

• Removal of pulmonary secretion

• O2 administration by mask for 24hrs.

• Fluid management

- Start IV therapy

-Monitor vital signs closely

• Catheterize & record urinary output hrly (adequate renal perfusion = 0.5ml / kg / hr.).

• Clean burn area with betadine or antiseptic solution & apply silver sulpha diazine cream.

• Tetanus toxoid, antibiotic, analgesic

• Dressing (closed/open method)

Fluid management (Parkland, Brooks & Evans)

Parkland Formula (>15-20% TBSA):

• In first 24hrs – 4ml RL X wt. in kg. X % of TBSA burned.

• One half amount of calculated fluid is given in first 8 hrs calculated from the time of injury.

• The remaining half of the fluid is given over next 16 hrs.

• Next 24 hrs. – 2ml of RL / kg / % of burns

Brook’s formula Fluid requirement :

• Estimate % of TBSA & accurate/approximate body wt.

• First 24 hrs. – colloids (blood,plasma,dextran) 0.5ml/kg/% of burn, saline 1.5ml/kg/% of burn.

• Second 24 hrs. – colloids 0.25ml/kg/% of burn, saline 0.75ml/kg/%of burn

NURSING MANAGEMENT

EMERGENT PHASE:

• Initiating emergency resuscitation.

• Orienting family member.

• Initiating prescribed therapies.

• Monitoring physiologic responses to treatment.

• Initiating measures to prevent later complications.

• Providing emotional support.

RESUSCITATIVE PHASE• Assessment of trauma

• Use of resuscitative measures

• Proper positioning

• Obtaining ECG,X-RAY and laboratories studies.

• Establishing the airway.

• Initiating fluid therapy.

• Inserting foley’s catheter.

• Completing initial wound evaluation and management.

Contd…..• Providing nutritional support.(Davies

formula : calories – 60Kcal/kg b.wt. + 35Kcal/1%of burn; Proteins 3g/kg b.wt. + 1g/1%of burn)

• Providing pain relief.

• Monitoring for complications.

REHABILATATIVE PHASE• Burn care.

• Providing skin care and wound management.

• Providing a physical exercise program.

• Providing for scar management.

Some facts about wound management

• Daily or twice daily

• Cleansing of wound with debridement (natural/ mechanical /surgical/Biological)

• Hydrotherapy (32degree C)

• Wound dressing after sedation or analgesic administration

• Environmental temp. (28-30 degree C)

• Sterile/clean technique

• Wound cleaning with NS

• Blisters can be pricked & fluid can be drained

• Open / closed method

• Application of antibacterial cream/ointment

• Surgery

• Grafting

Complications… Immediate :

• Shock (hypovolemic)

• Resp. tract injury (24-48hrs), pneumonia, resp. failure

• Septicemia

• Thrombophlebitis

• GI hemorrhage (7-10 days)

• Bone & joint abnormalities

• Seizures

Late :

• Anemia, Malnutrition, growth failure

• Post burn scar; cosmetic problems

• Psychological trauma

• Contractures

• Burn scar carcinoma (Marjolin’s ulcer)

HEMORRHAGE

• Hemorrhage is a condition in which a person bleeds too much and can not stop the flow of blood.

CLASSIFICATION

• IT IS CLASSIFIED ACCORDING TO APPEARANCE AS:

1. EARLY ONSET

2. CLASSIC ONSET &

3. LATE ONSET

EARLY

• Sign and symptoms of hemorrhagic disease typically appear within hours of birth.

SIGN AND SYMPTOMS:

• Oozing from the umbilicus or circumcision site

• Bloody or black stool

• Hematuria

• Epistaxis or bleeding from punctures.

CLASSIC

• It occurs usually at 1-7 days after birth

• Sign and symptoms are same as that of early onset

DIAGNOSTIC MEASURES:

1. Prolonged prothrombin time

2. Partial thromboplastin time

3. Fibrinogen level

4. Platelet count

LATE ONSET• It appears at approximately 2 -12 weeks of

age . This form occurs in totally or predominantly 2 to 12 weeks of age

CLINICAL MANIFESTATION:

• Evidence of intracranial hemorrhage

• Deep echymoses and

• Bleeding from the gastrointestinal tract, mucous membranes, skin punctures or surgical incision.

ASSESSMENT

• The prothrombin time ,blood coagulation time are prolonged.

• Levels of prothrombin (II) and factors (VIII),(IX) and(X)are markedly decreased.

• Haematemesis, epistaxis, malena

NURSING MANAGEMENT• Careful administration of vitamin-k into the

vastus lateralis muscle or ventrogluteal injection sites.

• Observe for signs of disorder.

• Notify the physician for appropriate diagnosis and treatment.

• Breast feeding mother are encouraged to increase their intake of food containing vitamin k eg. green leafy vegetables.

• Protection of child

• Education to parents

FOREIGN BODY INGESTION AND ASPIRATION

• Common in infants and children between the age group of 6 months and 3 years.

• Boys are twice as

likely as girl to

aspirate.

• Coins, nuts, metals,

bones, vegetables

and plastic objects

WHY …..• Small children are curious & innocent for

inserting various object into their orifices like mouth, nose, ears, anus & vagina.

• Severity is determined by the location, type of object aspirated, extent of obstruction.

SIGN AND SYMPTOMS

❑Dysphagia, choaking, gagging,

coughing

❑ Inability to speak

❑ Poor feeding

❑ Vomiting

❑ Neck or throat pain

❑ Refusal to eating or drinking

❑Cyanosis, dyspnea, stridor, wheezing

❑Unconsciousness, death

Treatment • Laryngoscopic or bronchoscopic removal of

foreign body.

• If the object is lodged in the larynx, tracheostomy may be necessary.

• After removal of foreign body, child is placed in a high humidity atmosphere.

• Antibiotics to prevent secondary infection.

• Observation.

NURSING MANAGEMENT

• Recognize the sign of aspiration →immediate removal.

• Foreign bodies should not be allowed to remain in the esophagus more than 24 hours

• Prepare the patient for flexible endoscopy if prescribed.

• Teach family and parents regarding prevention of foreign body ingestion.

4/18/2020

Contd……

• Teach children not to put anything in their mouth except food.

• Promote safe environment to infant and toddlers.

• Teach to immediately seek treatment if a child swallows an object.

• Prevent secondary infection

Prevention • Keeping small objects such as toys with

movable parts, safety pins, small candies, nuts, marbles out of children.

• Adult should not do such danger activities which children can imitate.

• Supervised play for small children.

• Teaching parents regd. safety & security

• Constant supervision

• (? Effect of mass media)

POISONING

• Common medical emergency in children.

• Under 5 yrs. of age all poisoning are accidental.

• Nearly 75% of all poisoning episodes involve ingestion of substance which are nontoxic or have mild toxicity.

• Poisoning is defined as a morbid condition caused by the ingestion of a toxic substance.

POISON!

• A poison is any substance that when ingested, inhaled or absorbed even in relatively less amounts can cause damage to a structure or disturbance of body function by its chemical action.

Definitions

• A poison exposure is the ingestion of or contact with a substance that can producetoxic effects.

• A poisoning is a poison exposure that results in bodily harm.

• Poison exposures can occur by accident without intent, and these exposures are defined as unintentional poisonings. In some situations, poison exposures are the result of a conscious, willful decision; these cases are defined as intentional poisonings.

Poisoning agents

Shannon M. N Engl J Med 2000;342:186-191

Agents Most Commonly Ingested by Children Less Than Six Years of Age, 1995 to 1998

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Epidemiology: “the numbers”

• Nearly 90% of exposures occurring at home

• During pre-adolescence : slight high in male

– This reverses in ages 13-19 with females accounting for 55 percent of poisonings

• Children, especially those under age 6, are more likely to have unintentional poisonings than older children and adults (Ref.- Litovitz 2001).

• Adolescents are also at risk for poisonings, both intentional and unintentional. About half of all poisonings among teens are classified as suicide attempts (Ref.- Litovitz 2001).

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Common clinical manifestations

• GI Disturbances : nausea, vomiting, anorexia, abdominal pain, diarrhea, discomfort.

• Respiratory & Circulatory : possible unexplained cyanosis, shock, collapse.

• CNS : lethargy, sudden loss of consciousness, convulsion, dizziness, coma.

• Approach begins with initial

evaluation and stabilization (ABCDE)!!!!!!!

• This is followed by a thorough approach

to identify the agent(s) involved

• Often, the suspected toxic agent will determine the priorities of management

• Supportive cares, prevention of poison absorption, antidotes, enhanced elimination may subsequently be involved

Approaching the Poisoned Child

Management for poisoning & overdose…

• Evaluation of child status in terms of immediate , potential or no danger.

• Weight & age to estimate level of potential toxicity.

• Time of ingestion

• Type, amount & route of exposure

Poisoning in ChildrenABC’s of Toxicology:• Airway• Breathing• Circulation• Drugs:

• Resuscitation medications if needed• Universal antidotes

• Draw blood: • chemistry, coagulation, blood gases, drug levels

• Decontaminate• Expose / Examine• Full vitals / Foley / Monitoring• Give specific antidotes / treatment

Poisoning in Children• Decontamination:

1. Ocular:– Flush eyes with saline

2. Dermal:– Remove contaminated clothing– Brush off– Irrigate skin

3. Gastro-intestinal:– Activated charcoal:

– May Prevent /delay absorption of some drugs/toxins– Almost always indicated

– Naso/oro-gastric Lavage– Bowel Irrigation:

– Recent ingestions 4-6 hrs– Awake alert patient– 500 cc NS Children / 2000cc adults– Oro / Nasogastric tube

Shannon M. N Engl J Med 2000;342:186-191

Agents Used for Gastrointestinal Decontamination in Children

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EMERGENCY ANTIDOTESPoison Antidote Dosage Comments

Cyanide Amyl nitrate 1-2 pearl /2 min. Then Na nitrat

Acetaminophen N-Acetyl cystiene 140mg/kg PO then 70mg/kg /4h. 17 doses

Effective within 16 h of ingestion

Atropine Physostigmine 0.01-0.03mg/kg IV Possible seizures, bradycardia

Benzodiazepine Flumazenil 0.01-0.02mg/kg IV 0.2 max.

Possible seizures, arrhythemia

β-Blocking agents Atropine 0.01-0.1mg/kg IV Min. dose 0.1mg

Calcium channel blockers

Glucagon 0.05-0.1mg/kg IV

Carbon monoxide Oxygen 100%,hyperparic

Coumarin Vitamin K 2-5mg IV/ SC Monitor PT

Cyclic antidepressants Sodium bicarbonate 0.5-1mEq/kg IV

Digoxin Digoxin–specific Fab antibody fragments

1 vial (40mg) neutralizes 0.6mg digoxin

Iron Deferoxamine 15-15mg/kg /hr IV

Isoniazid Pyridoxine Up to 250mg/kg/d for 5days

Lead EDTA= Edetate calcium BAL=Birish-anti-Lewisite DMSA=Dimercaptosuccinic acid. Penicillamine.

1500mg/m2/d for 5 days iv 3-5mg/kg/dose/4hr 3-7 d. 10mg/kg/day PO tid X5 d 20-30mg/kg/day PO /8hr

Mercury, Arsenic, Gold BAL 5mg/kg IM as soon as possible.

Nitrites/ methemoglobinemia Methylene blue 1-2mg/kg repeat 1-4 hr

Opiates,Darvon,Lomotil Naloxone 0,1mg/kg IV,ET,SC,IM up 2mg in children

Organophosphates Atropin 0.02-0.05mg/kg IV

EMERGENCY ANTIDOTES

Primary assessment & intervention

• Vital functions

• Maintain an open airway because some substance may cause soft tissue swelling of the airway.

• Ventilation and oxygenation

• Systemic support for airway security, ventilation, hemodynamic stability, and adequate CNS function

• Careful attention to pain and agitation

Subsequent assessment

• Identify the poison – try to determine the product taken : where, when, why, how much, who witnessed, time since ingestion.

• Call/rush to emergency.

• Obtain blood & urine tests or gastric contents for toxicology screening.

• Monitor fluid & electrolyte imbalance.

General interventionsSupportive care –

• Initiate IV access

• Administer O2

• Monitor & treat shock

• Prevent aspiration(sidelying with head down, use of oropharyngeal airway & suctioning).

• Insert urinary catheter to monitor renal function.

• Support child having convulsion.

• Monitor & treat – hypotension, coma, cardiac dysrrhythmia, seizure

• Gastric lavage (gastric aspirate

for toxicology screening).

• Forced diuresis (increased urine formation by isotonic fluid & diuretics)

• Hemoperfusion (process of blood through an extracorporeal circuit & a cartridge containing an absorbent, such as charcoal, after which the detoxified blood is returned to patient).

• Dermal cleansing with water or normal saline

– Pay close attention to burns, pain, infection

– Water is absolutely contraindicated with reactive metals; use mineral oil instead

– Tar can be removed safely with vaseline

• Hemodialysis

• Providing antidote -

Opiates, Lomotil – NaloxoneIsoniazid – PyridoxineIron – DeferoxamineAtropine – ProstigmineB-blocker – AtropineCA Channel Blocker – GlucagonCarbon Monoxide – OxygenBenzodiazepine - Flumazenil

Management Considerations• Prevention Strategies – (vigilance & firm guiding)

– Store potentially toxic substances in higher places or out of reach/sight or lock

– Store safe items within the child’s reach; don’t take medicine in front of kids

– Avoid keeping chemicals in the fridge

– Remove toxic plants; avoid exposure to toxic animals

– Keep matches, combustibles out of reach

– Dispose of partially consumed alcohol

– Read labels on products carefully

– Label poisonous substances with stickers & teach children

Management Considerations

• Drugs that can kill the toddler in one or two doses!:– Benzocaine, camphor, chloroquine, Lomotil,

Sulfonylureas, theophylline, phenothiazines, hydrocarbon aspiration.

“Prevention is the vaccine for the disease of injury.”

Drowning

DROWNING

• Drowning = process resulting in primary respiratory impairment from submersion/immersion in a liquid medium

• Submersion in a fluid resulting immediate death or death within 24hrs.

• Drowning without aspiration does not occur

Near Drowning

Is a submersion incident in which the individual survives for more than 24 hrs. irrespective of the eventual outcome.

EPIDEMIOLOGY• Freshwater drowning is more

common than saltwater drowning.

• Places: lakes/rivers/canals/pools

• Toddlers:

– Any container of water can be responsible:

• Buckets/fish tanks/washing machine/toilets/bathtub

Drowning modalities• Infants (age <1) - bathtubs, buckets & toilets

• Children ages 1-4 years - swimming pools, hot tubs & spas

• Children ages 5-14 years - swimming pools & open water sites

Near DrowningGroups at Risk

• Toddlers (40% of deaths < 5 yrs.)

• School age boys

• Teenagers

• Males > females (5:1)

• Children with:

– seizures

– cardiac dysrrhythmias

Toddler Drownings• Tend to occur because of

lapse in supervision

• Majority in afternoon/early evening-meal time

• Responsible supervising adult in 84% of cases

• Only 18% of cases actually witnessed

Causes of Near DrowningRecreational Boating

• 90% of deaths due to drowning

• Small, open boats

Recreational Water Activities

20% of deaths :

too few or no

floatation

devices !

Other CausesDiving Injuries

• Peak incidence 18-31 years

– No formal training

– 40-50% alcohol related

Ethanol & Water Activities

Epilepsy

• 2.5-4.6% of drowning victims had pre-existing seizure disorder

• Drowned children with epilepsy more likely to: be older than 5, drown in bathtub, not be supervised

Occupational Water Activities

Pathophysiology

Atelectasis

Aspiration leads to

collapse of the alveoli due to loss

of surfactant and

pulmonary edema

normal

alveoli

surfactant

collapsed alveoli

Pulmonary Edema

capillary

Interstitial fluid shift

AlveoliO2

CO2

Reduced perfussion

O2 CO2

Consequences • Panic, struggling, voluntary breath-

holding

• Aspiration of small amounts into larynx

• Involuntary laryngospasm

• Swallow large amounts

• Aspiration into lungs

• Hypoxia

• Anoxia

• Hypercapnia

• Acidosis

• Pulmonary edema

• Decrease in saturation

• Decrease in cardiac output

• Intense peripheral vasoconstriction

• Hypothermia

• Bradycardia

• Circulatory arrest

Labs & tests

• ABG – metabolic acidosis & hypoxemia

• Electrolytes changes

• CBC

• EKG

• CXR

Essential First Aid Management

Conscious Unconscious

Evaluate for CPR (prolonged)

Aspiration 100% oxygen

NO YES

Observe 100% oxygen transfer to hospital

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TreatmentTransport

• Continue CPR

• Establish airway → O2 as soon as possible

• Remove wet clothes

• Hospital evaluation

113

Immediate hospital management• Assess and manage ABC

• Humidified 100% oxygen at the rate of 8-10 L/min.

• Pulse oximetry

• Mechanical ventilation if required

• Aspiration of stomach contents

• ABGs & Electrolytes, CXR

• Observation

• Management of associated hypothermia

• Observe in ED for minimum 4-6 hours if:

– Submersion > 1 min.

– Cyanosis

– CPR required

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• IV access

• Administer drugs(electrolyte imbalance, metabolic acidosis)

• Foley’s catheter

• Bed rest with head elevation

• Monitoring (general condition,T.P.R, BP, I/O)

• Exogenous surfactant

• Re-warming ( 20-30degree to prevent hypothermia)

• ICP monitoring -

Low ICP → Better outcome

High ICP → Poor outcome

• Antibiotics

• Aseptic technique

Predicting Ability for Discharge

• Child can safely be discharged home if at 6 hours :

– GCS > 13

– Normal physical exam/respiratory effort

– Room air pulse oximetry oxygen saturation > 95%

The problem with looking well

Aspiration of water can cause late complications:

• Pulmonary oedema, Pneumonia, Haemolysis, Hepatic & renal failure, bowel necrosis

• Complications of hypothermia

Bad prognostic indicators• Submerged >10 min

• Time till BLS >10 min

• CPR >25 min

• Initial GCS <5• Age <3 years

• CPR in ER

• Initial ABG pH <7.1

• Initial core temp <330C

Near/ Drowning The Best Approach Therefore:

• P revention !

• P revention !

• P revention !

Prevention: Pool Fencing

Near Drowning Keeping Your Child Safe

• Never leave a child alone in or near water, even for a minute

• Limit pool access.

• Supervise closely when near any source of water

• Keep bathroom door closed

• Teach swimming & water safety measures

• Training of first aid & BLS

Prevention: Targeted Education

Children with Epilepsy: Safety Recommendations

• Child can swim in lifeguard-supervised swimming pool - no open water

• Leave bathroom locked

• Supervision!