• Poverty

• 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.

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

• Changes backed by legislation are the most successful.

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.

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).

In infants, as their skull sutures have not fused, cranial volume may increase from an extradural or subdural bleed before neurological signs or symptoms develop. The haemoglobin concentration may fall and they may become shocked.

Summary

Accidental head injury management

• Mild – discharge home with written advice

• Potentially severe – monitor to avoid secondary damage

• Severe – resuscitate, CT scan and neurosurgical referral.

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

This should be directed at:

• 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.

Summary

Burns and scalds

• Assess: need for resuscitation, if any smoke inhalation, depth and surface area of burns and if special sites involved

• Management: pain control, treat shock, provide wound care (cling film), refer to specialist centre if more than 5% full thickness, 10% partial thickness or significant burns to special sites.

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

Poisoning

Poisoning in children may be: