Chapter 52: Unintentional Injuries in Children Nursing Care

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Welcome back to The Deep Dive.

Today our mission is to get right into the high -stakes world of pediatric trauma.

We're pulling all the most critical protocols, the assessment findings, everything directly from chapter 52 of your text, which is all about unintentional injuries in children.

And this is so crucial because, you know, this is where you step out of that routine well child check.

Right.

And into the, I mean, the immediate chaos of an emergency department, unintentional injuries are the leading cause of death for children and adolescents, full stop.

So understanding this chapter is really about understanding your role as that first responder.

Okay.

Let's just jump right in then.

Let's set a scene that, you know, demands that high -level triage right away.

Imagine you're the charge nurse,

trauma bay.

A family arrives after a house fire, two kids.

Let's start with a 10 -year -old.

They jumped from a second story window to get out.

And the visible injury is like almost nothing, just a little red spot on their forehead.

But the vitals pulse is 62, respirations are 18, BP is 110 over 62.

Okay.

That pulse is a little low.

Very low.

And here's the kicker.

The left pupil is way more dilated than the right, and it's sluggish.

It's barely reacting to light.

And second patient,

the four -year -old.

Pulled out later, severe third degree burns all across their arms, their hands, and critically, their neck.

The neck.

The skin is white.

It's charred.

And the parent is just, you know, completely in shock.

We can't give you a coherent history at all.

So to you, the listener, you have to make a decision right now.

Who's the higher priority?

Is this emergent, urgent, less urgent, and why?

I mean, they're both emergent.

Absolutely emergent.

But the threats are totally different.

Right.

The four -year -old has third degree burns on the neck.

Any burn to the face, neck, throat, that's an immediate screaming red flag for airway edema, airway obstruction.

That can happen fast.

Incredibly fast.

So that's an immediate intervention to secure that airway.

Okay.

And the 10 -year -old, who honestly looks better on the surface?

The 10 -year -old is a textbook case of a life -threatening neurological crisis.

That specific combination, the low pulse, the high normal blood pressure, the unequal pupil, that is screaming increased intracranial pressure, ICP.

They are on a fast track to brain herniation.

So you've got two critical situations happening at the same time, both needing immediate action.

And it really sets the stage for this entire deep dive.

We're moving from, you know, what's expected in development to the physical and psychosocial changes that happen after a trauma.

Exactly.

We'll cover everything from how to stabilize that 10 -year -old's brain pressure to the very specific fluid management for the four -year -old's burns and even prevention for the rest of the family.

Okay.

Before we get into the weeds on these cases, let's just anger ourselves in the language of trauma.

Yeah.

There are a few key terms we should probably define right now.

Good idea.

Let's start with a couple related to head trauma.

When we talk about skull fractures later, you're going to hear otorhea and rhinorrhea.

Which is just fluid from the ear or nose.

Right.

Otorhea from the ear, rhinorrhea from the nose.

And recognizing it is so important because that clear fluid, it might actually be cerebrospinal fluid, CSF.

A direct line to the brain.

A direct line.

And for the burn victim, we'll talk about debridement, which is removing that dead tissue, and a procedure called escharotomy, which is cutting into the burn to restore circulation.

But let's flag two terms that aren't quite so obvious.

Okay.

First is plummism.

That's just the clinical term for lead poisoning.

Right.

It's not as acute as a burn, obviously.

But the neurological damage is profound and often permanent.

The second term is contrecoup injury.

Okay.

Explain contrecoup because that completely changes how you think about a simple bump on the head.

It really does.

So let's say a child falls and hits the back of their head.

That initial impact.

That's the coup injury.

Okay.

But the force makes the brain slam forward into the front of the skull and then recoil.

The contrecoup injury is that secondary impact on the opposite side.

And it can be worse than the first one.

Often much worse.

So as a nurse, you have to realize that a little bruise on one side of the head might mean there's severe hidden damage on the other.

Let's talk about the scale of this problem.

Why is this chapter, you know, a national health priority under Healthy People 2030?

The numbers are just, they're staggering.

Unintentional injuries are the absolute leading cause of death for everyone under 45.

Everyone.

Everyone.

For kids, that's over 12 ,000 deaths a year and 9 .2 million are treated in EDs for non -fatal injuries.

It's just, it's a massive problem.

So what does that look like in terms of, you know, actual goals that a nurse on the floor can impact?

The Healthy People 2030 targets give us some really specific things to aim for.

For instance, we're trying to reduce the death rate for kids aged one to 19.

The baseline was 25 .2 per 100 ,000.

And the target?

Is 18 .4.

That's a huge reduction.

That's thousands of lives saved.

And there's one specifically for poisoning, right?

Absolutely.

We're trying to cut down ED visits for medication overdoses in kids under five.

This is all about nurse -led education.

Secure storage, proper dosing, you know, using milliliters, not a random spoon from the kitchen which brings us to the nurse's dual role.

It's not just trauma care.

It's safety counseling and maybe the hardest part, assessing how the injury happened.

And that's a professional and a legal duty.

You have to assess, was this truly unintentional?

Was it self -inflicted?

Or, and this is the critical one, was it child maltreatment?

So what's a red flag?

If the story doesn't match the injury, the parent says the child fell off a couch, but the kid has a skull fracture.

Or the parent's story and the child's story are completely different.

That's a huge red flag.

You have to report it.

Okay, let's apply the nursing process to this.

When a child like our four -year -old burn victim comes in, the whole family is in crisis.

How do you even start?

Well, the assessment has to immediately include the family's psychological state.

The parents are terrified.

They're often drowning in guilt.

And that guilt can look like anger sometimes.

It can, but here's the clinical takeaway.

People under that much stress can't process information well.

So everything you're telling them is just going in one ear and out the other.

How do you deal with that?

Repetition.

You have to repeat everything.

Critical information, especially for discharge, you say it, you simplify it, and then you give it to them in writing.

You cannot trust a stressed parent to remember a complex medication schedule.

So the diagnosis have to be about more than just the physical injury.

Exactly.

It's not just third degree burns.

It's ineffective airway clearance, sure, but it's also parental fear related to uncertain outcome impaired family processes.

The emotional trauma is a patient care priority.

And with planning, you can't really do long term stuff right away.

So what are the absolute must haves for discharge?

Three things written and verbal instructions that you've gone over multiple times, a name and a 24 hour phone number for someone they can call with questions and clear follow up appointments.

What about consent during implementation in a true life or death emergency?

The exception is life actions.

CPR, stopping a massive bleed, securing an airway.

You don't wait for consent for that.

The law presumes a parent would consent to save their child's life.

And evaluation isn't just about a healed wound.

Not at all.

It's about physical healing.

Yes, but also psychological adjustment and prevention.

Is the child wearing a helmet now?

Can the parents show you where the chemicals are locked up?

That's a successful outcome.

We can tie this right into evidence based practice, right?

The QSEN connection.

We can.

A study by Damashek and Corliss found that injury rates go up with the number of kids in a house.

But the key finding was about supervision.

What kind of supervision works best?

It has to be both visual and proximity supervision.

You have to be close by and actually watching them.

Being in the next room listening or being right there, but staring at your phone.

That doesn't count.

The risk goes way up if you're both present and visually engaged.

That's a huge piece of counseling.

Let's get back to the trauma bay.

We've got our 10 year old and our four year old.

And the source makes a really critical point here.

Severely injured kids might not cry.

They might just be quiet.

And that silence is so deceptive.

It can mean they're in shock or neurologically compromised.

So your initial assessment has to be rigid.

A, B, C, D.

Airway, breathing, circulation, disability.

Walk us through what you're scanning for based on the tables in the chapter.

Okay.

Respiratory.

What's the rate?

The quality?

Do you hear stridor?

That high -pitched sound?

That's an airway closing.

Are they blue?

Are they restless?

That restlessness can be what we call oxygen hunger.

Then cardiovascular.

Right.

Cardiovascular.

Look for pallor.

That pale color that screams internal bleeding.

Is there obvious bleeding?

And the pulse.

An increasing pulse is your early sign of shock.

A decreasing blood pressure is the late really bad sign.

And finally D for disability.

The nervous system.

This is key for our 10 year old.

Exactly.

What's their level of consciousness?

Their LOC.

Are they awake?

Stuporous?

Comatose?

Are the pupils equal and reactive?

Any bumps or bruises on the head or spine?

That rapid scan guides everything.

And while you're doing all this, you need a history from parents who are falling apart.

What are the absolute must -ask questions?

What happened?

When did it happen?

Were they using any protective equipment?

If it was a fall, how high?

What did they land on?

And you have to remember kids can be unreliable historians.

So you compare the story to the injury.

If they say the kid fell one foot, but there are multiple fractures, that's a mismatch.

That's when you have to start thinking about child maltreatment.

Okay.

Let's focus in on head trauma for our 10 year old.

Before any scans, any monitors, what is the single most important first step?

Stabilize the head and neck.

Period.

Every trauma child gets a backboard and a C -collar.

Until you have imaging that proves the cervical spine is clear, you treat it like it's broken.

And from that moment on, you are doing continuous repeated neuro checks.

Okay.

Back to the 10 year old's vitals.

Low pulse, high normal BP, low -ish respirations.

That's the exact opposite of shock.

Why is that specific pattern the absolute telltale sign of rising intracranial pressure?

That's Cushing's triad.

It's a late ominous sign.

The swelling or bleeding inside the skull is crushing the brainstem where all the vital centers are.

So the brain isn't getting enough blood.

Right.

So the body goes into overdrive.

It jacks up the blood pressure to try and force blood past the obstruction into the brain.

But that huge spike in blood pressure triggers the vagus nerve, which slams the brakes on the heart.

Causing a low pulse.

Exactly.

A reflex bradycardia.

And it also suppresses the respiratory drive.

So you get a low pulse, low respirations, and a high blood pressure.

If you see that, you are in big, big trouble.

The pressure is critical.

So if the vitals go down, the danger is going way up.

What are the immediate next steps?

You get an ICP monitor in to measure the pressure directly.

CT or MRI to see the bleed.

And then you give hypertonic IV solutions like How does mannitol work?

Think of it like a super concentrated salt solution in the blood.

It creates this osmotic pull and it literally sucks the excess fluid out of the swollen brain tissue and back into the bloodstream so the kidneys can get rid of it.

And you keep the head elevated.

Always.

Keep the head of the bed up to help with drainage.

We might also use steroids like dexamethasone to help with the swelling.

And the two big nursing diagnoses here.

First is the risk of fluid volume issues because of those powerful IV fluids.

You are watching vitals constantly and you are meticulously tracking intake and output.

And urine specific gravity.

Why specific gravity?

Because if the brain swelling is compressing the pituitary gland, it can mess with antidiuretic hormone, ADH.

The specific gravity tells you if the kidneys are concentrating urine correctly or if there is a hormonal problem developing.

The second diagnosis is more long term.

That's the risk for delayed growth and development.

A brain injury doesn't end when they leave the hospital.

At every follow up, you are looking for subtle changes in thinking, any seizure activity, memory problems.

The goal is to get them back on their developmental track.

Let's talk specific injuries.

Skull fractures.

Most are simple linear fractures.

A single crack.

They just need observation and pain control.

But we worry about depressed fractures, where bone is pushing in on the brain, or compound fractures, where the skin is broken.

Those need surgery.

And what are the classic signs of a basal skull fracture?

One at the base of the skull.

Two things.

You look for raccoon eyes, which is bruising around both eyes, or battle sign, which is bruising behind the ear.

But the most critical finding is clear fluid drainage.

Rhinorrhea or otorrhea.

Exactly.

And if you see that, you have to test it for glucose.

Why glucose?

Because CSF has glucose in it, normal nasal drainage doesn't.

If it's positive, that means the meninges are torn and there's a huge risk for meningitis.

So what's the management for a confirmed CSF leak?

You admit them immediately, keep them in a semi -fowler's position to let it drain out, and you tell them very strictly, do not blow your nose, do not hold your nose, and the nurse must not pack the nostrils.

Okay, let's talk about bleeding inside the skull.

Chemotomas.

What's the difference between a subdural and an epidural?

A subdural is venous bleeding.

It's slow.

It's more common in infants, sometimes from non -accidental trauma.

Because it's slow, the symptoms of ICP might not show up for days, even weeks.

That's terrifying.

It is.

In an infant, if their fontanelle is still open, we can sometimes do a subdural puncture to relieve the pressure.

And an epidural hematoma.

That's the opposite.

It's arterial, usually the middle meningeal artery.

This is a rapid, catastrophic bleed.

And the classic deadly sign is the lucid interval.

The lucid interval.

The child gets knocked out, then they wake up, and they seem totally fine.

They're talking, they're lucid for minutes, maybe hours, and then they suddenly crash.

Vomiting, headaches, seizures.

It's a surgical emergency.

They need to go to the OR right now.

And the most common injury of all?

The concussion.

You mentioned the coup and contra -coup.

Right.

The coup is the first impact.

The contra -coup is the brain sloshing back and hitting the other side of the skull.

A concussion is basically a temporary disruption of brain function.

You'll see a brief loss of consciousness and amnesia.

For home care of a mild concussion, what's the most important instruction for parents?

And what myth do we need to bust?

They need to observe the child for 24 hours,

checking their level of consciousness every hour or two while they're awake.

And we have to bust the myth that if a child with a head injury goes to sleep, they'll die.

That is not true.

But you do have to wake them up, at least once during the night.

And when you wake them, you make sure they're actually oriented.

Ask them to name their favorite toy or a color.

Don't just shake them and let them go back to sleep.

Okay.

Now for the child who is unconscious,

coma versus stupor.

Stupor is when they're groggy, but you can rouse them with a strong stimulus, like a sternal rub.

Coma is when they're unconscious and you can't wake them up at all.

And what's the first physical intervention for a comatose child?

Turn them on their side.

Always.

It's to prevent aspiration of saliva or vomit.

We also rely heavily on what the pupils are doing.

Bilaterally fixed and dilated.

That's probably irreversible brain stem damage.

Pinpoint pupils.

Think opiates.

And we use the Glasgow Coma Scale, or GCS, to get an objective score.

Right.

The modified GCS for kids looks at eye opening, motor response, and verbal response.

A score of 15 is perfect.

A score of 3 is the deepest coma.

Anything less than 5 has a very, very poor prognosis.

And for nursing care, we're focused on airway, skin, and nutrition.

For the airway, they may need to be intubated and put on a ventilator.

For skin, you have to be relentless about preventing pressure ulcers.

Turning every two hours, special mattresses, range of motion, exercises, and nutrition when they can't eat.

They'll get nutrition through an IV or an NG or G tube.

But here's a critical point for NG tubes.

You always aspirate to check for residual stomach contents before you feed.

And you must return that aspirate to the stomach.

Why return it?

Because if you keep throwing away that stomach acid, you can cause a pretty severe metabolic alkalosis.

It's a simple thing, but it's really important.

And of course, constant mouth and eye care.

All right.

Let's shift gears to abdominal trauma.

The source material says this is found in about 25 % of major trauma cases.

And it's the most common cause of unrecognized fatal injury.

And the reason it's so deadly is because the signs can be so, so subtle.

A child's organs are just less protected by their ribs.

And in kids, a spleen injury is way more common than a liver injury, which is the opposite of adults.

So what are those subtle signs we're looking for?

It's really about the vitals.

Tachycardia, a fast heart rate, and pallor often show up before the blood pressure drops.

A dropping DP is a late sign.

So what are the diagnostic tools in the ED for this?

We might drop an NG tube to see if there's blood in the stomach.

We'll put in a Foley catheter to check for blood in the urine, which points to kidney trauma.

But really the gold standard to find out what's going on inside is a CT scan.

And during these procedures, which are terrifying for a kid, what's the communication strategy?

You have to talk to the child at their level.

And for the parents, you have to validate their fear and their guilt.

The source specifically points out that you should offer a referral to a trauma counselor or social worker right away.

Acknowledge that they're going through this massive crisis.

Now, what about pain management?

The source says we're often cautious about giving strong analgesics.

Why is that?

It's because we need pain as an assessment tool.

If the pain is getting worse or moving, that's our main clue that an organ might have ruptured or peritonitis is developing.

If you totally mask the pain, we lose that critical sign that they're getting sicker.

Let's focus on the spleen since it's the most commonly injured organ here.

Right.

Spleen ruptures are really common from things like improperly worn seatbelts or falling onto bicycle handlebars.

You're looking for tenderness in the left upper quadrant.

And there's a classic sign, right?

Yes, the care sign.

When the child is lying flat, they get pain that radiates up to their left shoulder.

That's from blood irritating the diaphragm and the pain gets referred up.

How is it managed?

If it's a minor bleed, sometimes just observation, but Sivu bleeding needs surgery, maybe even a splenectomy.

And if they do have their spleen removed, they are at a huge lifelong risk for infection.

They need a whole series of special vaccines.

Okay, let's move to dental trauma.

Very common.

A permanent tooth gets knocked out.

What is the one thing parents need to do immediately?

Time is everything.

Rinse the tooth gently in water, don't scrub it, and put it in a cup of milk or salt water.

Get it and the child to the ED immediately.

It can often be re -implanted.

And if a piece of the tooth is missing, you have to get a chest x -ray to make sure they didn't aspirate it.

No.

Drowning.

A tragically common cause of death.

3 ,500 kids a year.

And prevention is everything here.

We have to be relentless in counseling parents.

Four -sided fencing around pools,

constant undistracted adult supervision,

approved flotation devices, and reminding parents that toddlers can drown in a bucket of water.

Let's get into the pathophysiology.

It's dense, but understanding the fluid shifts is key.

So the first thing that happens is they inhale water, which causes a laryngeal spasm.

The airway just clamps shut.

If you can start rescue breathing, then the prognosis is great.

But if that spasm relaxes, water floods the lungs, leading to hypoxia and cardiac arrest.

And the type of water matters immensely.

Let's start with salt water.

Salt water is hypertonic.

It's saltier than blood.

So through osmosis, it pulls fluid out of the bloodstream into the lungs.

So the lungs get even more waterlogged.

Exactly.

And the blood gets thicker and you get hypovolemia, low blood volume.

In freshwater.

It's the opposite.

Freshwater is hypotonic.

So the fluid rushes from the lungs into the bloodstream.

This dilutes the blood, can cause hypervolemia, and critically, it causes hemolysis.

It ruptures the red blood cells.

Right.

And when all those red blood cells rupture, they release a massive amount of potassium, which can cause fatal cardiac arrhythmias.

But both types of water have one shared devastating effect on the lungs.

They both wash out the surfactant.

Surfactant is what keeps the little air sacs, the alveoli, from collapsing.

Without it, the lungs just collapse and you get ARDS, adult respiratory distress syndrome.

What about the mammalian diving reflex?

It's this incredible survival mechanism, mostly in young kids and very cold water.

It causes this profound slowing of the heart and shunts all the blood to the brain and heart, preserving oxygen for the most vital organs.

It can allow for survival after a surprisingly long time underwater.

For emergency care, it has to be CPR.

But hands -only CPR isn't enough, is it?

No.

This is a respiratory arrest first, not a cardiac one.

You have to give breaths.

Mouth -to -mouth or a bag -of -valve mask, you have to get that water out and oxygen in.

The psychological follow -up is huge.

It's a major nursing diagnosis.

Fear.

These kids can have terrible nightmares, a real phobia of water.

We have to encourage them to talk about it and help parents reintroduce them to water safely and slowly to regain that confidence.

Okay, let's turn to poisoning.

Over a million kids under six every year, and 90 % of it happens at home.

And it's usually things you wouldn't even think of.

Cosmetics, cleaning products, and increasingly prescription drugs that aren't locked up.

So prevention counseling is the absolute cornerstone of our job here.

What are the key take -home points for parents?

All medications and chemicals in a locked cabinet.

Not just a high one, a locked one.

Get rid of expired meds safely.

And post the poison control number, 1 -800 -222 -2222 on the fridge.

Call them first.

Always.

What do they need to have ready when they call?

The name of the substance, how much they think was ingested, when it happened, the child's age and weight, and what the child is doing right now.

Are they alert?

Are they sleepy?

Vomiting?

And once they get to the hospital, what's the go -to intervention for many swallowed poisons?

Activated charcoal.

It's this amazing substance that binds to a huge variety of toxins in the stomach and prevents them from being absorbed.

We give it orally or through an NG tube.

And the one thing you have to warn parents about?

It will make their child stool black for a few days.

It's harmless, but it can be really alarming if you don't warn them.

Okay, let's talk about specific poisons, starting with the most common one,

acetaminophen or Tylenol.

It's everywhere.

And the danger is severe, sometimes permanent, liver damage, hepatotoxicity.

The symptoms start out vague, nausea, vomiting, not wanting to eat, and then the liver enzymes start to climb.

And the antidote?

The specific antidote is acetylcysteine.

It works by protecting the liver cells from the toxic byproducts of the Tylenol breakdown.

The big challenge is that it smells and tastes absolutely horrible.

So how do you get a kid to take it?

You mix it with a strong soda, something to mask the taste.

Or you just have to give it through an NG tube to make sure it gets in and stays down.

Okay, let's contrast that with caustic poisoning.

Lye drain cleaners.

This is a whole different ballgame.

This is an immediate airway and surgical emergency.

These chemicals cause immediate severe burns to the mouth, the esophagus, the stomach, the swelling in the throat can completely block their airway in less than 20 minutes.

And there are two huge do -nots for this kind of poisoning.

Absolutely.

Number one, do not make them vomit.

You will just re -burn the entire esophagus on the way back up.

It's devastating.

And number two.

Do not give activated charcoal.

It doesn't work on lye.

And it coats everything in black gunk.

So the surgeon can't see the extent of the damage with an endoscope.

So what is the management?

It's all about securing the airway, sometimes with intubation or tracheotomy, and aggressive IV pain control with morphine.

And the long -term risk is just awful.

It is.

They are at a very high risk for developing an esophageal stricture, which is scar tissue that narrows the esophagus and requires repeated painful dilations.

And there's a correlation with esophageal cancer later in life.

Okay, iron poisoning, usually from prenatal vitamins that look like candy.

Exactly.

And iron is very tricky because the symptoms are biphasic.

What does that mean?

It means they get really sick right away, vomiting, diarrhea.

But then, for about six hours, they seem to get better.

Parents think the worst is over.

But it's not.

Not at all.

Internally, the iron is causing hemorrhagic necrosis.

And about 12 hours after they ate it, they crash.

Severe shock, massive GI bleeding, coma.

It can be fatal.

And the antidote.

The antidote is defroximin.

It's a chelating agent that binds with the iron so the body can excrete it.

And a key nursing point is to tell parents it will turn the urine a reddish -orange color.

Finally, let's cover plemism, lead poisoning.

The effects of lead are insidious and permanent.

It causes anemia, kidney damage, and most devastatingly, lead encephalitis, which is inflammation of the brain cells.

There is no safe level of lead.

Where does the exposure usually come from?

Bold paint.

Housing built before 1978.

The dust from peeling or chipping lead paint is the most common source for young children.

How is it diagnosed?

Lead tests.

A level over 5 in Tdl is considered poisoning.

On an x -ray of long bones, you can sometimes see these lead lines at the growth plates, which shows chronic exposure.

And the treatment is triton therapy.

Yes.

Depending on the level, we use agents that bind to the lead so it can be excreted.

But the most important intervention is getting the child out of the lead -filled environment.

Because the neurological damage that's already been done, it's irreversible.

Alright, let's move quickly through foreign body obstruction.

Our job here is mostly about safe removal and keeping the child calm.

Right.

In the ear, the big rule is do not irrigate if you think the eardrum is ruptured, or if it's something that will swell with water, like a bean or a peanut.

In the nose, a chronic foul smell is often the first clue.

What about things they swallow?

Coins, batteries, magnets?

A small coin will usually pass in a day or two.

Just have the parents check the stool.

But button batteries and magnets are emergencies.

Why?

A button battery can leak and cause a chemical burn.

And if a child swallows more than one magnet, they can stick together across different loops of bowel, causing perforation.

They have to be removed endostopically right away.

Okay, bites.

Dog bites are the most common.

About 90%.

The big risks are scarring and infection, including rabies.

You always have to document what animal did the biting, and human bites.

Sometimes that can be a sign of child maltreatment.

What about snake bites?

Most of the dangerous ones in the U .S.

are from kit vipers, rattlesnakes, copperheads.

Their venom causes intense local pain, swelling, and can mess with blood clotting.

What's the immediate first aid?

Keep the limb below the level of the heart.

A cold compress is okay, but the most important thing is what not to do.

Do not cut the wound and try to suck out the venom.

The old movie trope.

Exactly.

It doesn't work and it just causes more damage and infection.

Get them to the ED for anti -venom.

Okay, athletic injuries.

Super common.

The book specifically calls out trampolines for neck and spine injuries.

They are incredibly dangerous.

For simple strains and sprains, the treatment is Rice -E.

Rest, ice, compression, elevation.

Exactly.

Ice for the first 24 hours to bring down swelling, then you can switch to heat.

What about that unique elbow injury in young baseball players?

Ah, little leaguer's elbow.

It's basically an overuse injury that causes inflammation of the growth plate on the inside of the elbow.

If they don't rest it, it can cause permanent damage and deformity to the joint because those growth plates are still soft.

We're going to wrap up with thermal injuries, starting with cold.

Frostbite.

It's caused by peripheral vasoconstriction from the cold, usually affecting the nose, fingers, and toes.

The absolute most important part of management is gradual rewarming.

Not rabbit warming.

No.

If you warm the tissue too fast, its metabolic demand for oxygen skyrockets before the circulation has returned, and that causes even more cell death.

And be prepared for severe pain as the feeling comes back.

Okay.

Now let's bring it all back to our four -year -old from the beginning.

Burns.

Right.

Assessment is everything.

Extent, depth, and location.

And location is key.

A burn on the face or neck is an airway emergency.

A burn over a joint like a hand can cause a permanent contracture.

At first hand, the rule of nines for adults doesn't work on kids.

Not at all.

You have to use a pediatric specific chart, like a Lundrouter chart, because a child's head is proportionally so much larger.

And the depth of the burn determines if it hurts, right?

Exactly.

First and second degree burns are incredibly painful.

But a third degree, full thickness burn destroys the nerve endings.

So the center of the burn itself is numb.

It doesn't have sensation.

What are the electrical burns kids get from chewing on cords?

Those are really serious.

They cause a lot of edema, and the airway is a major concern.

They have to be observed in the hospital for at least 24 hours.

And long term, they often need a special mouth appliance to prevent the scar tissue from deforming their lip and cheek.

Let's focus on managing the severe burns like our four -year -olds.

The pain is immense.

It's unimaginable.

5 -E morphine epidurals.

It's aggressive pain management.

And the positioning is so hard.

To prevent contractures, you have to splint their joints in these awkward, hyperextended positions.

It's painful and distressing for everyone.

The fluid shifts.

This is the absolute core of burn management in the first 48 hours.

Walk us through it.

In the first 24 hours, the burn causes all the capillaries in the body to become super leaky.

Massive amounts of plasma fluid leak out of the blood vessels into the surrounding tissue.

Causing hypovolemic shock.

Severe hypovolemic shock.

And the electrolytes get completely messed up.

You get hyponatremia because sodium leaves with the water and hyperkalemia because all the damaged cells release their potassium.

The fluid resuscitation is massive.

Massive.

We use a formula based on their body surface area to calculate how much fluid they need and half of it has to go in within the first eight hours.

And we do not add potassium to the IV fluids at first.

And in about 48 hours, everything reverses.

The whole process flips.

The capillaries start to heal and all that fluid that leaked out rushes back into the bloodstream.

It's called the remobilization phase.

So now you have a risk of hypervolemia or fluid overload?

Exactly.

You have to watch them like a hawk and slow the fluids way down.

They'll start having massive urine output and now, because the kidneys are working over time, they can become hypovolemic and you might need to add potassium back in.

What about smoke inhalation from the fire?

It can be more deadly than the burn itself.

A hoarse voice, singed nasal hairs, any burns on the face.

That means you suspect smoke inhalation.

The immediate treatment is 100 % oxygen to displace any carbon monoxide.

And infection is the other huge risk.

After the initial shock, infection is the leading cause of death.

Their immune system is suppressed, so it's strict sterile technique for everything.

Gowns, gloves, masks.

The topical cream of choice is usually silver sulfateazine.

Let's talk about the surgical side.

What is an escharotomy?

The eschar is that tough, leathery, dead tissue from a third degree burn.

If it goes all the way around a limb, it acts like a tourniquet.

It cuts off circulation.

You have to make an incision through the eschar to relieve that pressure and restore blood flow.

It's a limb -saving procedure.

And grafting is the final step to healing.

Right.

First, you have to de -bride all the dead tissue away.

Then you can use temporary coverings like cadaver skin or pigskin.

But the permanent solution is an autograft, using a thin layer of the child's own healthy skin from another part of their body.

We have to close with the psychosocial side of this.

It's a long, brutal recovery.

It's paramount.

Social isolation is a huge problem because of all the infection control gear, the masks, the gowns.

It's terrifying for a child.

We have to find ways to provide comfort to let parents touch them, even with gloves on.

And the body image issues are lifelong.

They are.

These kids have to wear pressure garments for months or years to minimize scarring.

They often regress.

They get angry.

And a key intervention is to give them choices whenever you can.

To give them some control back.

To give them a little bit of control in a situation where they have none.

They have to get the dressing change, but they can choose which cartoon to watch while it happens.

It seems small, but it's everything.

Hashtag, shag, outro.

So we have gone from the first seconds of a trauma assessment all the way through the complex physiology and the long -term psychological recovery.

And the big takeaway here for any nurse is integration.

You have to know the complex physiology, the different patterns for ICP versus shock, the fluid shifts and drowning versus burns.

But you have to manage all of that while also managing the immense fear and guilt of the family.

It's about treating the entire family in crisis, not just the physical wound.

Exactly.

So let's leave you with one final thought.

Let's go back to our opening scene.

You have the 10 -year -old with a head injury, the 4 -year -old with severe neck burns, and a parent who is completely overwhelmed.

Considering everything we've talked about, the physical, the psychological, the preventative, which single nursing intervention do you think provides the most immediate and profound positive impact for that family in that moment of simultaneous trauma?

Think about what stabilizes the situation and provides a foundation for everything that comes next.

Indeed.

It's the difference between treating a symptom and treating the system.

This has been the Deep Dive.

Study hard and we'll catch you next time.