EMERGENCY SITUATIONS

CAR ACCIDENTS
CHECK FOR:
✓ Inability to wake the patient
✓ Severe or worsening headache
✓ Somnolence or confusion
✓ Restlessness or seizures
✓ Changes in vision
✓ Vomiting, fever or stiff neck
✓ Weakness or numbness

ASSESSMENT:
Face and head: Scrape, bruise, laceration, fracture, temporomandibular joint injury,
dental injury.

Brain: Concussion, post-concussion syndrome, closed head or traumatic brain injury

Neck: Sprain, strain, whiplash, fracture, cervical radiculopathy, disc injury

Shoulder and arm: Laceration, sprain, strain, fracture, dislocation, rotator cuff injury

Back: Sprain, strain, fracture, disc injury, lumbar radiculopathy

Leg, knee, foot: Laceration, sprain, strain, fracture, dislocation, ligament injury

Psychological: Post-traumatic stress disorder, acute stress reaction

1) HEADACHE
• Headaches that are most common in the urgent care center are tension
headaches, which can be related to simple cervical strains.
• The examiner should look for concerning physical signs, such as extensive
bruising and hematomas of the scalp, as well as a hematoma or bruit over the
lateral neck.

2) EPIDURAL HEMATOMAS
• A brief loss of consciousness at the time of the accident or an alteration in
behavior.
• Accumulation of blood form the lacerated artery may compress the brain and
cause a shift, leading to a declining level of consciousness and eventually a second
loss of consciousness with herniation and death.

3) SUBDURAL HEMATOMAS
• May be acute, subacute, or chronic.
• The patterns vary, but most patients present with headache, a decreased level of
consciousness, or focal neurological deficits.
• The initial injury may cause a small amount of bleeding and go unnoticed. If
sufficient further bleeding occurs, intracranial pressure may rise and cause herniation.

4) POST-CONCUSSIVE SYNDROMEA
 • Post-concussive syndrome is a common sequela to traumatic head injuries, and
may present with headaches, dizziness, inability to concentrate, or irritability that
many persist for several weeks following the injury.
• This can be a diagnosis of exclusion, as these patients may need neuroimaging
and further testing initially to rule our intracranial bleeding.

5)NECKPAIN
• A detailed history and physical, as well as consideration of radiography, are
essential in the evaluation of the patient with posttraumatic neck pain. Such a patient
should be observed for movement and resting posture of the head and neck.
• PALPATE: Trapezius, Paraspinal Muscles, Spinous Process
• Check for cervical range of motion.
• Most common: SELF-LIMITING MYOFASCIAL STRAIN
- Pain that originates from myofascial trigger points in skeletal muscle. It is
prevalent in regional musculoskeletal pain syndromes, either alone or in combination
with other pain generators.
• CERVICAL STRAIN – Occurs with the abrupt flexion/extension movement of
the cervical spine. Abrupt movement from one side to the other and rotational trauma
can be involved.

• In a patient with severe pain, restricted range of motion, or radicular symptoms,

consideration should be given for advanced imaging. • When there is a concern for
bony abnormalities without cord injury, CT scanning is often preferred.
• When there is a concern for cord injury because of signs and symptoms such as
bilateral paresis or paresthesia, MRI is often preferred.

6)CHEST PAIN AND BLUNT CHEST TRAUMA- A complete visual inspection

should be done, looking for a paradoxical movement of the chest wall, and identifying
all wounds on the chest and back. The exact location, appearance, number, and type
of wounds should be noted and well documented. • Auscultation for absent or
diminished breath sounds may indicate a pneumothorax or hemothorax.
• Palpation of the chest wall should be done carefully, feeling for subcutaneous
emphysema or bony crepitus.
• An electrocardiogram should be performed in all patients.

7) ABDOMINAL PAIN & BLUNT ABDOMINAL TRAUMA

● Solid organs may be lacerated, vessels may be disrupted, or a hollow viscus
may rupture, depending on the extent of the trauma.
● Check for pain, tenderness, or peritoneal signs.
● The abdominal wall should be evaluated for ecchymosis, distention, decreased
bowel sounds.
● Bruising over the abdominal wall in the distribution of the seat belt indicates
intraabdominal injury.

● Abdominal distention may be a result of an ileus or gastric distention, while

decreased bowel sounds may result from chemical peritonitis caused by blood or a
ruptured hollow viscus.
● Laboratory studies should be individualized to each patient, with the
recognition that there may be nonspecific elevations of various enzyme levels in the
setting of trauma.
8) LIFE THREATENING INJURIES
 Transection of the aorta
 Patients with a history of a rapid deceleration injury should be evaluated with a
chest x-ray and possibly a chest CT, especially if the patient has persistent pain or
dyspnea.
 In patients who appear clinically stable without a concerning mechanism of
injury, further evaluation may not be necessary with the exception of obtaining an
ECG.

9) TYPICALLY NON LIFE – THREATENING INJURIES

 Multiple rib fractures can be a predictor of more serious injuries.
 Specifically, patients with pain of the lower ribs with pleuritic complaints and
abdominal pain are at higher risk for both significant intra-thoracic and intra-
abdominal injuries.
 These patients should be assessed for hypoxia, tachypnea, abnormal lung sounds,
and discomfort on the abdominal exam, with further work-up pursued
accordingly

T Y P E S O F I N J U R I E S:
1. HEAD AND NECK INJURIES Traumatic brain injury, concussions, whiplash,
contusions, and skull base fractures. Severe traumatic brain injuries can result in
temporary or even permanent developmental problems, behavioral problems, or
cognitive difficulties.

2. AIRBAG INJURIES One of the biggest causes of injury in this case is the front-
passenger airbag, which may break the noses or even the necks of smaller passengers.

3. CAR SEAT INJURIES While riding without proper child restraints is far more
dangerous than securing a child in a car seat, these devices can cause injuries if they
fail during a crash.

4. GLASS INJURIES A broken window or windshield can cause cuts (lacerations) on

a child’s face, dental injuries and facial trauma.

5. CHEST INJURIES Tightening restraints and contact with the seat in front can
cause children to suffer thoracic injuries, including rib fractures, lung injuries, and
internal bleeding.

6. FRACTURES Wrist, hand, foot fractures, broken pelvis from a seat belt, and
fractures in femurs and arms.

7. PERMANENT DISABILITY Spinal cord injuries, loss of limb, or nerve damage.

8. PSYCHOLOGICAL DIFFICULTIES Even if a child did not suffer head trauma in

the crash, he or she is still at risk of psychological problems due to the emotional and
physical effects of the accident.

HEALTH PROMOTION & RISK MANAGEMENT:

 Children under 4 ft 9 in. tall must sit on a car/booster seat when riding in a car.
 Use window gates and guards to protect children from falling out.
 Teach children how to cross the street safely by looking both ways for cars.

BASIC LIFE SUPPORT:

1. Check to see if the child is conscious

2. Make sure you and the child are in safe surroundings
3. Look quickly to see if the child has any injuries, bleeding, or medical problems
4. Check breathing
5. Place your ear near the child’s mouth and nose
6. Begin chest compression
7. If the child doesn’t respond and isn’t breathing:
• Carefully place the child on their back. For a baby, be careful not to tilt the head
back too far. If you suspect a neck or head injury, roll the baby over, moving their
entire body at once.
• For a baby, place two fingers on breastbone. For a child, place heel of one hand
on center of chest at nipple line. You also can push with one hand on top of the other.
• For a child, press down about 2 inches. Make sure not to press on ribs, as they
are fragile and prone to fracture.
• For a baby, press down about 1 1/2 inches, about 1/3 to 1/2 the depth of chest.
Make sure not to press on the end of the breastbone.
• Do 30 chest compressions, at the rate of 100 per minute. Let the chest rise
completely between pushes.
• Check to see if the child has started breathing.
• Continue CPR until emergency help arrives.
8. Do rescue breathing.
• To open the airway, lift the child’s chin up with one hand. At the same time, tilt
the head back by pushing down on the forehead with the other hand. Do not tilt the
head back if the child is suspected of having a neck or head injury.
• For a child, cover their mouth tightly with yours. Pinch the nose closed and give
breaths.
• For a baby, cover the mouth and nose with your mouth and give breaths. •
Give the child two breaths, watching for the chest to rise each time. Each breath
should take one second.

9. Repeat compressions and rescue breathing if the child is still not breathing.
• Two breaths can be given after every 30 chest compressions. If someone else is
helping you, you should give 15 compressions, then 2 breaths.
• Continue this cycle of 30 compressions and 2 breaths until the child starts
breathing or emergency help arrives.

TREATMENTS & RECOVERIES:

1. HEAD AND BRAIN INJURY

Treatment:
✓ Rest
✓ Cut back on physical activities and activities that require a lot of
concentration.
✓ If more severe concussion symptoms are present, you may need to go to the
hospital. You may have bleeding under the skull (subdural hematoma). Bleeding in
the skull is a medical emergency.

Recovery:
✓ For mild concussions, most patients notice symptoms diminish in 2 to 3 weeks
after onset. The recovery from a subdural hematoma is more complicated and depends
on the severity of the injury.

2. FACIAL INJURIES
Treatment:
✓ Cuts may need stitches.
✓ Scrapes may be bandaged.
✓ For the more serious injuries, such broken facial bones, surgery may be
needed.

Recovery:
✓ The time needed will depend on the severity of the injuries. Scrapes will take a
few days to weeks to heal. Surgical repairs may take weeks to months to heal.

3. NECK INJURIES
Treatment:
✓ Mild neck strain may be treated with overthe-counter pain relievers. ✓A
dislocation or other serious vertebrae injury may require surgery.

Recovery:
✓ Recovery time after surgery will vary depending on the procedure needed. Full
recovery can take months.

4. COLLARBONE & RIB INJURIES

Treatment:
✓ A broken collarbone may heal on its own, usually immobilized with special
braces.
✓ If the damage is more extensive, surgery may be needed.

Recovery:
✓ The healing process may take 6 to 16 weeks.

5. BACK & SPINAL CORD INJURIES

Treatment:
✓ For minor back pain, rest and ice or heat application, along with over-the-
counter pain relievers.
✓ If pain doesn’t go away in a couple of weeks, see primary care physician for
an evaluation and get a referral to see a chiropractor.
✓ More severe injuries, such as spinal cord injury, broken bones or muscle tears,
may require surgery.

Recovery:
✓ Minor muscle strains should heal within weeks. Muscle tears that need surgery
may require therapy and months to heal.
✓ Bones that are surgically repaired normally require 3 to 4 months to fully heal.
 ✓ With spinal injuries, your body will do most of its healing work in the first 6
months after the injury. Physical functions that aren’t restored in the first year after
injury will likely not return.

6. INTERNAL INJURIES
Treatment:
✓ For muscle strains, do RICE (Rest, Ice, Compression, Elevation). ✓ If
minimal internal bleeding is suspected, the doctor may observe the patient to see if the
bleeding will stop on its own.
✓ For severe internal bleeding, surgery may be required

Recovery:
✓ Times will vary widely depending on the extent of the injuries and the
treatment required.
✓ In the case of internal bleeding, the best outcomes result when prompt
professional medical care is received.

7. LOWER EXTREMITY INJURIES

Treatment:
✓ For minor injuries, do RICE and over-thecounter pain relievers. ✓ For
broken bones, a cast or other external support may be applied. ✓ For more severe
breaks, surgery may be required, as well as physical therapy.

Recovery:

✓ A broken leg may need from 6 to 8 weeks. As with other injuries, more time
will be needed for more severe injuries. Therapy may be in important part of
recovery.

8. PSYCHOLOGICAL INJURIES
Treatment:
✓ A counselor may suggest anxiety management, meditation or other tools to
reduce anxiety

Recovery:
✓ There is no set time for recovery from the psychological trauma. Seek
guidance from a mental health care professional if you have concerns about the
mental aspects of recovery.

HEALTH EDUCATION:

1. PHYSICAL WELLBEING DURING RECOVERY- Taking a mindful approach to

the food you are eating and focusing on your physical therapy will significantly
improve your road to recovery

2. EXERCISE- While consulting with providers during treatment visits, ask physician
what sort of exercise routine or at-home physical therapy they recommend while you
recover. While it is important to stay active for a healthy routine, it is equally
important to not overexert or participate in exercise that could be detrimental to
recovery. Always be as transparent as possible about your symptoms or improvement
with your doctors to ensure they are recommending the right plan that will fit your
specific needs.Carving out time and staying consistent with your physical therapy is
essential. Attempt to enlist your family members to help you stick to a routine. Set
reminders, be extremely patient with yourself, and don’t give up on your physical
therapy programs.

3. DIET- Consult your physician for the best diet plan, depending on your dietary
restrictions or even specific injury, certain foods may be the perfect supplement to
treating injury, while others should be avoided. Fruits and vegetables have vitamins
and minerals that can help fight the inflammation that may be causing part of the pain.
Simply eating healthy foods can help alleviate some of the symptoms of injuries

4. MENTAL HEALTH AFTER AN ACCIDENT- Consult your physician for the best
diet plan, depending on your dietary restrictions or even specific injury, certain foods
may be the perfect supplement to treating injury, while others should be avoided.
Fruits and vegetables have vitamins and minerals that can help fight the inflammation
that may be causing part of the pain. Simply eating healthy foods can help alleviate
some of the symptoms of injuries.

FALLS

ASSESSMENT:
 History of falls
 Mental status changes
 Sensory deficits
 Balance and gait
 Use of mobility assistive devices
 Disease-related symptoms
 Medications
 Unsafe clothing
 Assess the patient’s environment for factors known to increase fall risk such as
unfamiliar setting, inadequate lighting, wet surfaces, waxed floors, clutter, and
objects on the floor.
 Refer the patient with musculoskeletal problems for diagnostic evaluation.

RISK FACTORS FOR FALLS:

 Poor vision
 Foot problems
 Lower body weakness
 Vitamin D deficiency
 Home Hazards
 Medications
 Difficulties in mobility or balance

PLANNING & IMPLEMENTATION OF CARE:

✓ Never leave your baby unattended in high places, such as on a tabletop, in a crib
with the sides down, or even on a bed or sofa.
✓ Don't leave your baby unattended in any infant seat or "sitting" toy, such as a
swing or jumper. Use all the safety straps provided.
✓ Don't use baby walkers. Walker injuries can include pinches and falls. Walkers can
cause severe accidents, such as a fall down a flight of stairs. ✓ Keep your baby away
from elevated porches, decks, and landings.
✓ Never leave your baby alone in or around a bathtub.
✓ Make your home safe from falls by removing hazards that might cause a fall.
✓ As soon as your baby can walk, lock doors to all dangerous areas. Keep keys out
of your child's sight and reach.
✓ Be careful when using equipment such as high chairs and changing tables. Always
use the safety straps, and keep a close eye on your child.
✓ Keep stairways clean and safe. Carpeting on stairs should be in good repair.
Uncarpeted stairs should be kept clean but not slick. Train your child to hold on to the
rail and to walk carefully down each step one at a time. If you have pets, teach your
child to keep away from them while on stairs.
✓ Attach double-sided tape, foam backing, or a rubber pad to throw rugs to secure
them on flooring.
✓ Watch your toddler when he or she is outside. Uneven grass, sloping lawns, and
hills can make walking difficult.
✓ Have your child stay seated when he or she is eating or drinking. And don't allow
your child to walk or run with any objects in his or her mouth. Your unsteady toddler
could get face and mouth injuries in addition to other injuries from a fall.
✓ Install window guards. Also, don't place furniture, including chairs, close to
windows. Make sure windows are closed and locked securely when children are
present.
✓ Don't allow your child to climb on high furniture
✓ Watch out for playground equipment, especially slides and monkey bars. Avoid
taking your child to playgrounds that don't have a soft surface beneath the equipment.
✓ Trampolines. Even with constant adult supervision and protective netting, many
children are injured on them. It's best to keep your child off trampolines.
✓ Tricycles. Only allow your child to ride solid, stable tricycles that are low to the
ground. Make sure your child wears a helmet. Also, watch where your child rides.
Steep downhill slopes can make your child lose control and fall.
✓ Falling off the bed. Install bed rail guards to help prevent falls. Many are now
available that are easy to attach and remove. Make sure openings in rails are small
enough to prevent a child from getting trapped, which can lead to choking or
suffocating

BASIC LIFE SUPPORT:

▪ Approach them calmly and reassuringly be alert to any dangers to either you or the
casualty.
▪ Do not rush to move them. Get onto the floor so you are the same level as them and
immediately.

Assess:
1. ARE THEY RESPONSIVE?
• Not responsive – Are they breathing?
• If they are breathing: Look closely how they have fallen and carefully put them
into the recovery position to keep their airway clear. • If they are not breathing:
Start CPR immediately and act according to your organization’s emergency policy.
Request a defibrillator immediately if there is one available.

2. IF THE PERSON IS RESPONSIVE

• Talk to them. Try and ascertain how the accident happened and if there could be
any medical cause – do not stress them if they are confused. • Try and work out
where it hurts most and look at them closely to see if there is any obvious bleeding,
bruising or contorted limbs indicating a particular injury.
• If they are conscious and you think they may have fallen from a height or could
have injured their neck or spine – do not move them. Try and keep them as still as
possible and discourage them from twisting. Phone an ambulance and calmly keep
reassuring them until paramedics arrive.
• If you are aware of any bleeding apply firm pressure with a clean pad whilst
awaiting the First Aid Kit.
• If they start to show signs of clinical shock – lie them back and raise their legs
and get medical help.

3. IF THERE IS NO OBVIOUS INJURY OR MEDICAL CAUSE FOR THE FALL

• Carefully and very slowly help them into a sitting position – watch them
carefully for any signs of pain, discomfort or dizziness.
• With help, carefully assist them into a chair, or back to bed.
• Very carefully and reassuringly check them over completely to ensure that there
is no unseen injury – this is particularly important with diabetics when they may not
feel where they have hurt themselves.

TREATMENTS & RECOVERIES:

➢ When a fall results in a serious injury such as a hip fracture, the course of
treatment required may be intensive. Some fractures such as a hip flexor require
surgery, medication, and rehabilitation.
➢ In some cases, an individual may not be considered a good candidate for surgery.
➢ For individuals who sustain a stable fracture, bed rest may be ordered instead of
surgery. This is due to the fact that in a stable fracture, the fractured bones are aligned
in a way that may allow them to heal on their own without surgery.

1. PARTIAL HIP REPLACEMENT- In a partial hip replacement, a surgeon will

replace the damaged ends of a broken bone with a prosthesis.

2. TOTAL HIP REPLACEMENT– In a total hip replacement surgery, the upper

femur and the socket of the pelvic bone are replaced with a prosthesis.

3. INTERNAL REPAIR USING SCREWS- In this procedure, metal screws are

placed in the fractured bone to hold it together during healing. A metal plate to assist
in proper healing may also be used.

REHABILITATION AFTER A FALL INJURY:

In the case of a hip fracture, rehabilitation will be started as soon as possible.
Often, physical therapy begins within a day of surgery. This physical therapy will
often be done at the bedside in a hospital room with a physical therapist working to
ensure the child does not lose ability from being in bed for too long. A patient in
 rehabilitation may be asked to sit in a chair for as long as they are able to
tolerate. This may reduce the risk of bed sores and blood clots.

While still in hospital, patients will be asked to do strengthening exercises and to

stand and walk with assistance and support. After walking is able to be accomplished
safely, stairs may be attempted.

Depending on the surgery and the child’s individual circumstances, more

intensive rehabilitation after discharge from hospital may be needed.

HOME HEALTH CARE AFTER A FALL:

1. A home health care agency will allow an individual to receive physical and
occupational therapy at home. Therapists will work with the patient at home, helping
them navigate their surroundings and home. Therapists may also be able to ensure that
the home is safe and that risks of future falls are minimized.

2. When using home health care, nurses will also come to the home. Nurses will assist
with treatments, medications, pain management and any needed post-surgical care
such as wound care. Home health aides will assist with ADLs such as dressing,
toileting and showering.

3. Other professionals such as dieticians, social workers, speech therapists, or

respiratory therapists may also come to the home depending on the individual and
their specific needs and plan of care.

4. When recovering from a fall, an individual and their family should meet with
several home health care agencies to assess which one best suits their needs.

BITES
Children are bitten by snakes and animals such as dogs or raccoons; they occasionally
are bitten by other children. In an emergency room, the source of a bite needs to be
documented because human bites can also result from child maltreatment.

1. M A M M A L I A N B I T E S- Dog bites, cat bites, wild animal bites, and human

bites constitute a threat, although these are less common in children. All of these bites
can cause abrasions, puncture wounds, lacerations, and crushing injuries related to the
size of the animal and the location of the bite. (DANGER OF RABIES)

2. S N A K E B I T E S- Snakebites tend to occur during the warm months of the year,

from April to October.(DANGER OF VENOM)

ASSESSMENT:
1. Puncture marks begins to appear, accompanied by pain at the site (purplish
erythema and edema)
2. Fluids may be oozing from the bite.
3. Systemic symptoms such as dizziness, vomiting, perspiration, and weakness may
be present.
4. VENOM: Interferes with the blood coagulation, the child may have hematemesis.
The pupils may be dilated, showing potent effect on the cerebral centers. If not
treated, seizures, coma, and death may result.

EMERGENCY AT THE SCENE:

✓ Apply cold press to the bite.
✓ Urging the child quietly, with the bitten extremity dependent also helps to slow
circulation.
✓ Commercial snakebite kits such as suction should be used.
✓ Always remember: Excising the bite with knife and sucking out the venom orally
is of questionable value, and if the person administering the treatment has open mouth
lesions, the procedure could be dangerous. Excising the bite can also lead to
secondary infection and if done too vigorously, it can injure tendon or muscle. It is
vital to transport the child to health care facility as quickly as possible.
✓ Ask the child to describe the snake.
✓ Specific antivenin depending on the type of snake is then administered. ✓ If
giving the serum, do not inject it into an edematous body part because it will be
poorly absorbed from edematous tissue. Assure the parents that giving antivenin must
be on the opposite limb.
✓ If the child’s immunization is unknown or it has been more than 10 years since the
immunization was given, ask if tetanus prophylaxis should be administered.
NURSING DIAGNOSIS:
Fear related to seriousness of child’s condition.

HEALTH EDUCATION:
 Look for snakes before stepping into underbrush
 Be aware that snakes sun on warm rocks
 Do not lift up rocks without looking at what could be under them.
 Listen for the telltale sound of a rattlesnake
 Know the markings of poisonous snakes to help avoid them.

BURNS / SMOKE INHALATION:

• Burn injury is the result of heat transfer from one site to another. • Burns disrupt the
skin, which leads to increased fluid loss; infection; hypothermia; scarring;
compromised immunity; and changes in function, appearance, and body image.
• The severity of each burn is determined by multiple factors that when assessed help
the burn team estimate the likelihood that a patient will survive and plan for the care
for each patient.

Burns are classified according to the depth of tissue destruction as superficial

partialthickness injuries, deep partial thickness injuries, or full thickness injuries.

1. SUPERFICIAL PARTIAL THICKNESS- The epidermis is destroyed or injured

and a portion of the dermis may be injured.
2. DEEP PARTIAL THICKNESS- A deep partial thickness burn involves the
destruction of the epidermis and upper layers of the dermis and injury to the deeper
portions of the dermis.
3. FULL THICKNESS- A full thickness burn involves total destruction of the
epidermis and dermis and, in some cases, the destruction of the underlying tissue,
muscle, and bone.
PHYSICAL ASSESSMENT:
1. RULE OF NINES- ▪ A common method, the rule of nines is a quick way to
estimate the extent of burns in adults through dividing the body into multiples of nine
and the sum total of these parts is equal to the total body surface area injured.

2. LUND AND BROWDER METHOD- ▪ This method recognizes the percentage of

surface area of various anatomic parts, especially the head and the legs, as it relates to
the age of the patient.
▪ For children and infants, the Lund-Browder chart is used to assess the burned
body surface area. Different percentages are used because the ratio of the combined
surface area of the head and neck to the surface area of the limbs is typically larger in
children than that of an adult.

3. PALMER METHOD- ▪ The size of the patient’s palm, not including the surface
area of the digits, is approximately 1% of the TBSA, and the patient’s palm without
the fingers is equivalent to 0.5% TBSA and serves as a general measurement for all
age groups.

SMOKE INHALATION SYMPTOMS:

Numerous signs and symptoms of smoke inhalation may develop. Symptoms may
include cough, shortness of breath, hoarseness, headache, and acute mental status
changes.

1. Signs such as soot in airway passages or skin color changes may be useful in
determining the degree of injury.

2. Cough: When the mucous membranes of the respiratory tract get irritated, they
secrete more mucus. Bronchospasm and increased mucus lead to reflex coughing. The
mucus may be either clear or black depending on the degree of burned particles
deposited in the lungs and trachea.

3. Shortness of breath: This may be caused by direct injury to the respiratory tract
leading to decreased oxygen getting to the blood. The blood itself may have decreased
oxygen-carrying capacity. This could be the result of chemicals in the smoke or the
inability of cells to use oxygen. This can lead to rapid breathing resulting from the
attempt to compensate for these injuries.

4. Hoarseness or noisy breathing: This may be a sign that fluids are collecting in the
upper airway where they may cause a blockage. Also, chemicals may irritate vocal
cords, causing spasm, swelling, and constriction of the upper airways.

5. Eyes: Eyes may become red and irritated from the smoke. The corneas may also
have burns on them.

6. Skin color: Skin color may range from pale to bluish to cherry red.

7. Soot: Soot in the nostrils or throat may give a clue as to the degree of smoke
inhalation. Inhalation can lead to nostrils and nasal passages swelling.
8. Headache: In all fires, people are exposed to various quantities of carbon
monoxide. Even if there are no respiratory problems, carbon monoxide may still have
been inhaled. Headache, nausea, and vomiting are all symptoms of carbon monoxide
poisoning.

9. Changes in mental status: Chemical asphyxiants and low levels of oxygen can lead
to mental status changes. Confusion, fainting, seizures, and coma are all potential
complications following smoke inhalation.

PLANNING & IMPLEMENTATION OF CARE:

Management:
On site management (first aid: Cool, Cover, Call): The basic principles of first aid
remain the same for all categories of burns with some specific management for
particular category. Rescuer should take care of his/ her own safety before helping
burn victim.

a) Initial management includes assessment and maintenance of following parameters

with ABCDE approach:
 Airway assessment and management in case of inhalational burns (burns in
closed space, deep dermal burns to face, neck, or trunk, singed nasal hair ,carbon
particles in oropharynx).
 Breathing: beware of inhalation and rapid airway compromise.
 Circulation: ensure fluid replacement by securing wide bore intravenous line
through which Ringer lactate solution can be given rapidly. Oral fluids such as
ORS (Oral rehydration solution) may be given after initial resuscitation.
 Disability: Evaluation for neurological deficit or any gross disability.
Compartment syndrome occurs when excessive pressure builds up inside an
enclosed space in the body. The legs, arms, and abdomen are mostly affected by
compartment syndrome. Treatments for compartment syndrome focus on
reducing the dangerous pressure in the body compartment. Dressings, casts, or
splints that are constricting the affected body part must be removed.
 Exposure: (Percentage area of burn), the whole of a patient should be examined
(including the back) to get an accurate estimate of the burn area and to check for
any concomitant injuries.

b) In all cases, tetanus prophylaxis should be administered.

c) Wound care:
▪ Adherent necrotic (dead) tissue should be cleaned. ▪ After debridement, the burn
should be cleansed with either 0.25% (2.5 g/litre) chlorhexidine solution or 0.1%
(1 g/litre) cetrimide solution, or with mild water based antiseptic. (Do not use
alcohol-based solutions).
▪ A thin layer of antibiotic cream (silver sulfadiazine) should be applied.
▪ The burn area is dressed with petroleum gauze and dry gauze thick enough to
prevent seepage to the outer layers.
d) Systemic antibiotics are given to treat and prevent wound infections.
e) Proper nutrition with adequate supply of energy and proteins should be given to
patients.
f) Specialized care may be provided during healing process in the form of skin grafts
or surgical release of contractures due to scars.

FIRST AID:
Do’s:
• Stop the burning process by removing clothing, jewelry and irrigating the burns.
• In electrical burns, put the main switch off as quickly as possible and use a wooden
scale or rod wooden chair to push the victim away from electricity. (No such
maneuver should be attempted while a person is connected to a high voltage source,
as the current is likely to “arc” to the rescuer as he approaches)
• Extinguish flames by pouring plain water; if water is not available by applying a
blanket and removing the blanket as soon as the flames are put off.
• In chemical burns, remove or dilute the chemical agent by irrigating with large
volumes of water.
• Use cool running water to reduce the temperature of the burn.
• Wrap the patient in a clean cloth or sheet and transport to the nearest appropriate
facility for medical care.
• Take care of fractures and probable injuries during transportation.
• Ensure A-Airway, B-Breathing & C-Circulation before transportation to higher
center

Dont’s:
• Do not start first aid before ensuring your own safety (switch off electrical current,
wear gloves for chemicals etc.)
• Do not apply ice because it may further damage the injured tissues.
• Avoid prolonged cooling with water because it may cause hypothermia (low
temperature).
• Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn or any other
material.
• Do not open blisters with needle or pin, until topical antimicrobials can be applied,
such as by a health-care provider.

PREVENTION:
PRIMARY PREVENTION:
• Enclose fires and limit the height of open flames in domestic environments. Cooking
on floor should be avoided.
• Restrain playing of toddlers in kitchen/cooking area.
• Watch the child constantly especially around gas burners, stoves, ovens,
microwaves, heaters and other appliances.
• Turn pot handles toward the back or center of the stove to prevent tipping. • Never
cook while holding a child.
• Carefully use electrical appliances and switch off all electrical appliances when not
in use.
• Avoid use of unauthorized gas cylinders & kerosene stove/chulha. Use safe stoves
and lamps.
• Avoid loose clothing while cooking. Tie up loose saree end (pallu) or stole (chunni)
properly.
• Never hold a cup of hot liquid near infant/toddlers.
• Check the temperature of water before bath.
• Beware of high-tension wires passing over terrace or balcony and do not keep open
electrical wires at home.
SECONDARY PREVENTION:
Both pre-hospital and hospital care play an important role in the management of burn
patients by preventing deaths and disability.

FIRST AID: Education and sensitization of individuals/communities on the site

management in the form of first aid can further help in early recovery of the burn
patients.

BETTER HOSPITAL CARE: These include better initial treatment to prevent shock
and breathing problems, better infection control, increased use of skin grafts and
assuring adequate nutrition. These measures can minimize the burden of death,
disability and suffering from burns.

TERTIARY PREVENTION:
Rehabilitation: Burn survivors are often left with disability and disfigurement that
interferes with their future life. Rehabilitation measures such as physical therapy and
addressing psychological issues can assure a better life in burn survivors.

MEDICAL TREATMENT:
After you have received first aid for a major burn, your medical care may include
medications and products that are intended to encourage healing.

1. Water-based treatments. Your care team may use techniques such as ultrasound
mist therapy to clean and stimulate the wound tissue.
2. Fluids to prevent dehydration. You may need intravenous (IV) fluids to prevent
dehydration and organ failure.

3. Pain and anxiety medications. Healing burns can be incredibly painful. You may
need morphine and anti-anxiety medications — particularly for dressing changes.

4. Burn creams and ointments. If you are not being transferred to a burn center, your
care team may select from a variety of topical products for wound healing, such as
bacitracin and silver sulfadiazine (Silvadene). These helps prevent infection and
prepare the wound to close.

5. Dressings. Your care team may also use various specialty wound dressings to
prepare the wound to heal. If you are being transferred to a burn center, your wound
will likely be covered in dry gauze only.

6. Drugs that fight infection. If you develop an infection, you may need IV antibiotics.

7. Tetanus shot. Your doctor might recommend a tetanus shot after a burn injury.

PHYSICAL & OCCUPATIONAL THERAPY:

If the burned area is large, especially if it covers any joints, you may need physical
therapy exercises. These can help stretch the skin so that the joints can remain
flexible. Other types of exercises can improve muscle strength and coordination. And
occupational therapy may help if you have difficulty doing your normal daily
activities.
SURGICAL & OTHER PROCEDURES:
You may need one or more of the following procedures:

• Breathing assistance. If you've been burned on the face or neck, your throat may
swell shut. If that appears likely, your doctor may insert a tube down your windpipe
(trachea) to keep oxygen supplied to your lungs.

• Feeding tube. People with extensive burns or who are undernourished may need
nutritional support. Your doctor may thread a feeding tube through your nose to your
stomach.

• Easing blood flow around the wound. If a burn scab (eschar) goes completely
around a limb, it can tighten and cut off the blood circulation. An eschar that goes
completely around the chest can make it difficult to breathe. Your doctor may cut the
eschar to relieve this pressure.
• Skin grafts. A skin graft is a surgical procedure in which sections of your own
healthy skin are used to replace the scar tissue caused by deep burns. Donor skin from
deceased donors or pigs can be used as a temporary solution.
o Allografting – is the grafting of skin (sterilized and frozen) from cadavers or a
donor on the cleaned burn site. These grafts do not grow but provide a temporary
protective in the burn site
o Autografting – is a process in which a layer of skin of both epidermis and a part
of dermis is removed from a distal, unburned portion of the child’s body and placed
over the prepared burn site, where it will grow and replace the burned skin.

CHOKING
Choking occurs when a foreign object lodges in the throat or windpipe, blocking the
flow of air. In adults, a piece of food often is the culprit. Young children often
swallow small objects. Because choking cuts off oxygen to the brain, give first aid as
quickly as possible.

PHYSICAL ASSESSMENT:
SIGNS OF CHOKING:
The universal sign for choking is hands clutched to the throat. If the person doesn't
give the signal, look for these indications: o Inability to talk o Difficulty breathing or
noisy breathing
o Squeaky sounds when trying to breathe
o Cough, which may either be weak or forceful
o Skin, lips and nails turning blue or dusky
o Skin that is flushed, then turns pale or bluish in color
o Loss of consciousness

WHAT CAUSES CHOKING?

Children usually choke from placing objects in their mouths. They normally do this
out of curiosity. However, they may also choke when eating too quickly or when
talking with food in their mouths.

o Common objects that children choke on are:

 ▪ popcorn
▪ candy
▪ pencil erasers
▪ carrots
▪ hot dogs
▪ chewing gum
▪ peanuts
▪ cherry tomatoes
▪ whole grapes
▪ large pieces of fruit
▪ large pieces of vegetables

Adults usually choke when swallowing food without chewing properly or when
laughing while eating or drinking

WHAT ARE THE COMPLICATIONS ASSOCIATED WITH CHOKING?

The complications of choking include:
▪ throat irritation
▪ throat damage
▪ death from asphyxiation

NURSING DIAGNOSIS:
✓ Impaired swallowing
✓ Risk for aspiration

HEALTH PROMOTIONS & RISK MANAGEMENT:

 You can prevent your child from choking by keeping their play area free of
small objects, such as coins, erasers, and building blocks. Chop your child’s
food into small pieces, making it easier for them to swallow. Discourage your
child from talking while eating

 Prevent yourself from choking by chewing your food completely, avoiding

talking or laughing while eating, and keeping water near you while eating
 THE HEIMLICH MANEUVERS Follow these steps to perform the Heimlich
maneuver:
1. Stand behind the person with your arms wrapped around their waist.
2. Lean the person forward.
3. Ball your hand into a fist and place it on the person’s abdomen, above their navel.
4. Use your free hand to grip your fist and press into the person’s abdomen in an
upward motion.
5. Repeat this method five times.
6. If the object is still stuck in the person’s throat, repeat these steps five more times.
7. If the person is unconscious, clear their airway if possible. You can do this using
your finger. However, be careful not to push the object further into the throat. Call
911 or your local emergency services, and then begin CPR.

 CPR (CARDIOPULMONARY RESUSCITATION) You should follow these

steps to perform CPR:
1. Lay the person down on their back, on a flat surface.
2. Kneel on the side of the unconscious person and place your hand in the
 middle of their chest, palm down.
3. Place your free hand over the top of the other. Lean forward with your
shoulders and push down quickly, 100 times per minute. This is called chest
compression.
4. Repeat this process until the person starts breathing again or medical help
gets there

POISONING
CHILD POISONING:
▪ It is important to take steps to prevent poisoning, which can cause very serious
effects in children. Because their bodies are smaller and less developed than those of
adults, children are especially susceptible to the effects of toxic substances.
▪ Poisoning can affect many parts of the body, including the lungs, heart, central
nervous system, gastrointestinal tract, and kidneys.
▪ Most poisonings in children are unintentional and occur in the home. More than
half of reported poisonings occur in children under age five. A child may become
curious and ingest a toxic substance, inhale it, or absorb these substances through the
skin.

CIRCUMSTANCES OF POISONING:
❑ Commonly accidental especially in the under-5 age group.
❑ Homicidal
❑ Suicidal (in older children)

1. Medication Medications account for about half of potentially toxic exposures. A

child may ingest medications found in the home or a parent may unintentionally give
a child more than the correct dose. Exposure to either prescription or over-the-counter
medications can be poisonous.

2. Household Products and Pesticides Poisoning can occur from the ingestion or
inhalation of household substances, such as bleach or toilet bowl cleaner, laundry
detergent pods, pesticides or insecticides, glue, paint thinners and removers, and oven
and drain cleaners.

3. Carbon Monoxide Dangerous levels of carbon monoxide, which is a colorless,

odorless, and poisonous gas, may be emitted from fuel-burning appliances that aren’t
working properly or aren’t properly vented. These include space heaters, furnaces, gas
ranges and ovens, clothes dryers, gas water heaters, portable generators, wood-
burning fireplaces and stoves, and automobiles.

4. Household Plants Some indoor and outdoor plants contain toxins that can affect the
stomach, heart, liver, respiratory system, or skin.

5. Alcohol, Nicotine, and Illicit Substances Alcohol intoxication can affect children
who drink alcoholic beverages, including wine, beer, and liquor. Alcohol can also be
found in perfume, mouthwash, cleaning products, hand sanitizers, and over-the-
counter cold medications. In children, alcohol poisoning can cause low blood sugar,
which can lead to seizures and coma.
6. Hydrocarbons Hydrocarbons include gasoline, kerosene, lamp oil, lighter fluid,
paint thinners and removers, and motor oil. Young children may unintentionally
ingest these fluids.

7. Batteries Items such as watches, calculators, remote controls, and toys may be
batterypowered. Children may swallow small batteries, particularly flat “button”
batteries. Batteries may contain alkaline chemicals that can leak or generate an
electrical current, which can cause burns or holes in the esophagus.

8. Personal Care Products Some personal care products, such as nail polish remover
or perfume, can be poisonous if ingested. Exposure to these products may lead to
symptoms including vomiting, drowsiness, or difficulty breathing

INITIAL ASSESSMENT & MANAGEMENT:

A. Non specific management:
1) removal of the source of poison away from the child
2) initial resuscitation and stabilization
3) removal of unabsorbed poison from GIT
4) elimination of already absorbed poisons
5) symptomatic and supportive measures
6)
B. Removal of the poison:
Skin : triple wash ( water, soap more water)
Eyes: saline wash.
Cavities: removed by irrigation.

C. Initial resuscitation and stabilization - it is the initial priority in treating poison

children.
a) Assess airway patency.
b) Assess the adequacy of breathing .
c) Assess the circulation in terms of:
✓ cardiovascular status.
✓ effect of circulatory inadequacy to other organs.
d) Assess neurological function in terms of:
✓ bedside blood glucose concentration.
✓ level of consciousness
✓ pupillary size and reaction
✓ presence of any seizure activity.
e) Record the child’s temperature

D. Removal of unabsorbed poison from the GIT

1. ACTIVATED CHARCOAL (AC):
- it is the safest mode.
- It is given if the child has taken a potentially toxic overdose within the previous
hour.

Mechanism and dose: - It absorbs many toxins (except metals, alcohols & petroleum
distillates) & reduces its absorption into the bloodstream. Dose: 1 g/kg.
Disadvantage: It is an odorless, tasteless, black powder so Children may be averse to
its gritty texture & color.
If they cannot be cajoled with flavoring, an opaque cup, and straw, then it can be
administered by a nasogastric tube.

2. GASTRIC LAVAGE
- usually reserved for children who present within 1 hour of ingesting a
potentially life threatening poison.

Disadvantage:
• It is often difficult to remove the toxic agent from the GI tract because of the small
size of lavage tube needed in pediatric patients.
• The child will often need to be intubated to facilitate this technique.

3. WHOLE-BOWEL IRRIGATION
• Irrigation is a newer technique used to flush the toxin through the bowel ,
thereby preventing further absorption.
• Polyethylene glycol 500 ml/h is given orally & continued until the rectal
effluent is clear (in 4-6 h).
• Serial abdominal radiographs may also be used to demonstrate its effectiveness.
• It is particularly useful for ingestions that are not adsorbed by AC such as:
(Lead paint,iron tablets, batteries and hypotension)
4. Elimination of the already absorbed poisons Absorption of poisons occurs after six
hours after ingestion.
The techniques are:
❑ forced diuresis
❑ peritoneal dialysis
❑ hemofiltration
❑ hemodialysis
❑ hemoperfusion
❑ plasmapheresis
❑ exchange transfusion.

Symptomatic Rx:
• arrhythmia
• convulsions
• hypothermia
• pain

IRON POISONING:
▪ Iron poisoning occurs when a person, usually a child, swallows a large number of
iron-containing pills, most often vitamins.
▪ Acute iron poisoning mainly involves children under age 6 who swallow pediatric or
adult vitamins containing iron. These children may not be able or willing to tell you
what and how much they swallowed.
▪ Iron preparations are widely used and are available without a prescription and may
be housed in bottles with or without child resistant closures.

IRON POISONING CAUSES

❑ Iron pills can look like candy to children.
❑ Intentional overdose can occur among adults, but is rare.