Accidents, poisoning and child protection
The risk of accidents, poisons and abuse is increased by:
• Poor-quality, overcrowded homes
• Lack of a safe environment for play
• Poor parenting skills, which may be due to parental psychiatric illness, drug and alcohol abuse, violent temperament, poor education or lack of social support.
Accidents
Accidents (now often called ‘unintentional injuries’) are extremely common. In the UK, one in four children attend an A&E department each year; about half because of an accident. They are more common in boys. Most accidents cause only minor injury but can also be fatal. Injuries, mostly accidents, and poisoning are the major cause of death in children 1–14 years of age in the UK (Figs 7.1, 7.2). Accidents also cause significant disability and suffering, including post-traumatic stress disorder. Head injury with brain damage is the major cause of disability from accidents. Cosmetic damage following burns, scalds and other accidents may cause the child profound psychological harm.
Injuries are the most common cause of death in children over 1 year of age.Accident prevention
The prevention of childhood accidents is clearly important. Doctors and nurses who treat children and see the effects of accidents are particularly well placed to provide the community with advice on appropriate preventive measures (Fig. 7.3). In order to prevent accidents:
• The relationship between an individual type of accident and the child’s developmental level must be considered
• Specific solutions should be based on detailed epidemiology, e.g. child-resistant containers are the best method to limit children’s access to medicines
Organisations such as the Royal Society for the Prevention of Accidents and the Children Accident Prevention Trust are important resources in helping reduce accidents by providing education and lobbying for legislative changes, e.g. bicycle helmet wearing.
The number of children killed in accidents has declined markedly over the past 20 years.Road traffic accidents
Road traffic accidents (RTAs) are the most common cause of accidental death or serious injury in childhood and in 2008 accounted for 23 000 children killed or injured on the UK’s roads. RTAs can be divided into several types.
Pedestrian road traffic accidents
Children’s involvement in road traffic accidents is mostly as pedestrians. Boys between the ages of 5 and 9 years are at maximum risk, particularly after school. Children are unable to estimate the speed or dangers of traffic and to foresee dangerous situations. Social and economic factors play a part, with children in social class 5 being 5 times more likely to be killed as a pedestrian than children in social class 1.
Head injuries
Minor head injuries in childhood are common, and the vast majority of children recover without suffering any ill effects. However, about 1 in 800 of these children develop serious problems. The aim of the management of head injuries is to identify those children requiring treatment and to avoid secondary damage to the brain from hypoxia or poor cerebral perfusion (Fig. 7.4).
Head injury may result in concussion, a reversible impairment of consciousness, a subdural or extradural haematoma or intracerebral contusion (see Ch. 27).
Internal injuries
Children may suffer internal injuries associated with severe trauma. These include:
• Abdominal injuries, including a ruptured spleen, ruptured liver, kidney and bowel. There should be a high index of suspicion for these internal injuries if there has been abdominal trauma or if the clinical setting suggests significant inflicted, i.e. abusive, injury. The child needs close observation. Abdominal ultrasound (focused abdominal sonography in trauma – FAST scan) and X-rays, including CT scan, may be helpful. If there is any doubt, a laparotomy/laparoscopy is undertaken. Intra-abdominal injuries such as a contained splenic bleed are increasingly managed conservatively with close monitoring, but paediatric surgical support must be available immediately in case surgery is required.
• Chest injuries, including pneumothorax and haemopericardium, may require emergency treatment. These children should be managed in a paediatric intensive care unit.
Burns and scalds
Burns and scalds are a significant accidental (and non-accidental) cause of death, although most of the deaths occurring in house fires are caused by gas and smoke inhalation rather than thermal injury. Scalds in toddlers are common; children are scalded at lower temperatures than adults, as their skin is thinner. It is important to exclude inflicted burns.
Management
The severity of the injury is assessed:
• Is the airway, breathing and circulation satisfactory?
• Was there any smoke inhalation? If this has occurred, there is a danger of subsequent respiratory complications and carbon monoxide poisoning. All affected children should be observed and managed in hospital, with a low threshold to protect the airway before secondary problems develop.
• Depth of the burn. In superficial burns, the skin will be epithelialised from surviving cells. In partial thickness burns, there is some damage to the dermis with blistering, and the skin is pink or mottled; regeneration for superficial and partial thickness burns is from the margins of the wound and from the residual epithelial layer surrounding the hair follicles deep within the dermis. In deep (full thickness) burns, the skin is destroyed down to and including the dermis and looks white or charred, is painless and involves hair follicles, hence skin grafting is often required. Deep burns need assessment and treatment in hospital.
• Surface area of the burn. This should be calculated from a surface area chart (Fig. 7.5). The palm and adducted fingers cover about 1% of the body surface. Burns covering more than 5% full thickness and 10% partial thickness need assessment by burns specialists. Involvement of more than 70% of the body surface carries a poor chance of survival.
• Involvement of special sites. Burns to the face may be disfiguring, those to the mouth may compromise the airway from oedema, and those to the hand/joints may cause functional loss from scarring. Burns to the perineum and other special sites should all be referred to a burns unit.
Treatment
• relieving pain, assessed with a pain score; may require the use of strong analgesics such as intravenous morphine
• treating shock with intravenous fluids, preferably plasma expanders, and close monitoring of haematocrit and urinary output. Children with more than 10% burns will require intravenous fluids
• providing wound care. Burns should be covered with cling film (plastic wrapping), which reduces pain from contact with cold air and reduces the risk of infection. Blisters should be left alone. Irrigation with cold water should only be used briefly to superficial or partial thickness burns covering less than 10% of the body as it may rapidly cause excessive cooling. Tetanus immunisation status must be ascertained and a booster given if required. Ongoing care involves removal of dead tissue and placement of sterile dressings.
Severe burns or significant burns to special sites are best dealt with in specialist units. Plastic surgeons will often need to embark on a programme of skin grafts and treatment of contractures. The psychological sequelae of severe burns are often marked and long-lasting, and appropriate psychological support is required.
Drowning and near-drowning
Drowning is a significant cause of accidental death in children in the UK. Most victims are young children. Drowning is three times more common in boys than in girls. Warmer, affluent countries tend to have a higher incidence of drowning than in the UK, particularly because of drowning in domestic swimming pools. Babies may drown in the bath, toddlers may wander into domestic ponds or swimming pools, and older children may get into difficulty in swimming pools, rivers, canals, lakes and in the sea. Children should always be supervised when swimming.
Near-drowning
Up to 30% of fatalities can be prevented by skilled on-site resuscitation. Even children who are unconscious with fixed dilated pupils can survive near-drowning episodes, particularly if the water is cold, due to the protective effect of hypothermia against hypoxic brain injury. Children who are unconscious with fixed dilated pupils should therefore be fully resuscitated until their temperature is nearly normal. Immediate management at the waterside is with mouth-to-mouth resuscitation and chest compressions. Heat loss should be prevented by covering and warming. Children who may have inhaled water should be admitted to hospital to be observed for signs of respiratory distress from pulmonary oedema after 1–72 h from secondary surfactant. Some aspirate water and develop pneumonia with secondary infection. It is now thought that there is no difference in outlook for fresh- and salt-water drowning.
Choking, suffocation and strangulation
Children may choke on vomit, toys or food. Some children may strangle themselves accidentally on curtain cords, bedding and necklaces. Most are accidents but some such injuries are inflicted deliberately as a form of child abuse. Some adolescents deliberately hang themselves.
In airway obstruction from an aspirated foreign body, the actions outlined in Figures 7.6 and 7.7 should be followed.
Inhaled foreign body
Dog bites
Most dog bites are minor, but severe lacerations, particularly to the face, do occur, especially in the toddler age group.
Wound management is as important as antimicrobials in preventing infection:
• Copious wound irrigation, toilet and debridement
• Delayed wound closure, especially on limbs, due to increased incidence of infection
• Prophylactic antibiotics if wounds or child is at increased infection risk, i.e. puncture wounds, bites to hands/wrists, crush wounds with devitalised tissue, bites to genitals, child has diabetes mellitus, immunosuppression and in all bites after primary closure.
The antibiotic of choice is co-amoxiclav, as this also covers Pasteurella infection.
Although there has been much publicity about fierce dog breeds, such as Rottweilers, attacking children in parks or public places, most attacks are by dogs known to the child.
Poisoning
• accidental – the vast majority
• deliberate self-poisoning in older children
• non-accidental as a form of child abuse
Accidental poisoning
Although many thousands of young children are rushed to doctors’ surgeries or hospital for urgent medical attention following accidental ingestion, most do not develop serious symptoms, as they ingest only a small quantity of poison or take relatively non-toxic substances (Table 7.1). However, a small percentage of children become seriously ill and a very few children die from poisoning each year.
Table 7.1
Potential toxicity in accidental poisoning in infants and young children, with some examples
| Toxicity | Medicines | Household products | Plants |
| Low | Oral contraceptives, most antibiotics | Chalk and crayons, washing powder | Cyclamen, sweet pea |
| Intermediate | Paracetamol elixir, salbutamol | Bleach, disinfectants, window cleaners | Fuchsia, holly |
| High | Alcoholic drinks, digoxin, iron, salicylate, tricyclic antidepressants | Acids, alkalis, petroleum distillates, organophosphorus insecticides | Deadly nightshade, laburnum, yew |
Most accidental poisoning is in young children, with a peak age of 30 months. Inquisitive toddlers are unaware of the potential danger of taking medicines, household products and eating plants. Most ingestions occur in the child’s own home, when supervision is inadequate. Supervision of toddlers entails not only reacting to a dangerous situation but also prevention through anticipation.
The aim of management of poisoning should be to prevent unnecessary admissions to hospital while maintaining safety. There has been a marked reduction in the hospital admission rate for poisoning. Reasons for this include:
• The introduction of child-resistant containers – in the UK they must be used for paracetamol and salicylate preparations, and certain household products, such as white spirit; an alternative container for tablets is opaque blister packs
• The reduction in the number of tablets per pack
• A reduction in prescriptions of potentially harmful medicines, e.g. aspirin and iron.
Management
Clinical features that may alert one to poisoning are shown in Table 7.2; however, in young children parents usually know the identity of tablets or other poisons taken (Table 7.3). Management is outlined in Figure 7.8.
Table 7.2
| Tachypnoea | Aspirin, carbon monoxide |
| Slow respiratory rate | Opiates, alcohol |
| Hypertension | Amphetamines, cocaine |
| Hypotension | Tricyclics, opiates, β-blockers, iron (secondary to shock) |
| Convulsions | Tricyclics, organophosphates |
| Tachycardia | Cocaine, antidepressants, amphetamines |
| Bradycardia | β-blockers |
| Large pupils | Tricyclics, cocaine, cannabis, amphetamines |
| Small pupils | Opiates, organophosphates |
Table 7.3
| Poison | Adverse effects | Management |
| Alcohol (accidental or experimenting by older children) | Monitor blood glucose. Intravenous glucose if necessary. Blood alcohol levels for severity | |
| Acids and alkalis | Inflammation and ulceration of upper gastrointestinal tract leading to stenosis |
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