CHAPTER 1
PREVENTION OF INJURY
Injury is a leading cause of death and permanent disability in children and young adults in all countries. Most parents worry about how to let a child explore and learn, yet protect them from accidents. What is an ‘accident’? Many injuries in children could be avoided by adequate supervision and common-sense measures, so in a purest sense many are truly ‘accidents’. When true neglect to care for a child’s safely occurs it is important that we identify it and know what to do (see Chapter 14, Non-accidental Injury).
As health professionals we have a role in educating the families we see and our local community, while striking a balance between advising on injury prevention and encouraging activity and sports for the child’s future health. We can be quite influential. A few gentle words of advice at the time of an injury are often remembered. So it is a good opportunity to talk about the patterns of injury that we regularly see when we spot an injury which could have been avoided.
Most injuries to children less than three years of age occur in the home or garden. At this age children develop rapidly, and their carers often underestimate their capabilities. When children become older they attend nurseries or schools, and move further from home for play and other activities. Many incidents leading to injury then occur in schools and sports facilities or in the neighbourhood. As children reach adolescence, injuries occur further from the home or in high-risk places (railway lines, derelict buildings) where bored teenagers seek adventure. There is a strong association between injury rates and social deprivation.
Many organisations exist in developed countries to promote injury prevention and have leaflets and websites with information. In the UK, health visitors assist families with accident prevention. Health professionals should be familiar with advising on simple measures such as:
Inexpensive safety equipment, e.g. stair gates, fire-guards
Child-resistant containers for medicines
Safe storage of household cleaners and garden products
Safe positioning of hot objects, e.g. cups of tea, kettles, pans, irons
Safe use of equipment, for example not to put babies in baby bouncers or baby chairs on work surfaces and to always supervise the use of baby walkers
Safety awareness on roads and railways
Cycle helmets when riding a bicycle
Worldwide, the most effective way to reduce death and disability has been through compulsory (legal) interventions such as the wearing of seat-belts in cars, fencing around open water, wearing crash helmets when on a bicycle/motorbike/horse, safety locks on the windows of buildings over one storey high and severe speed restrictions in residential areas. Many of these legal interventions came about because we as healthcare professionals raised awareness of the problem, assisting with data collection or noticing local safety hot-spots, and bringing our concerns to local and national level.
CHAPTER 2
PAIN MANAGEMENT
Introduction
What are we treating?
Assessment of pain
How to treat pain
Procedural sedation
INTRODUCTION
Minor injuries cause pain. Recognition and alleviation of pain should be a priority when treating injuries. This process should ideally start on arrival to your facility and finish with ensuring that adequate analgesia is provided at discharge.
Pain is often under-recognised and under-treated in children. There are several reasons for this. Assessing pain in children can be difficult. For example, children in pain may be quiet and withdrawn, rather than crying. Communication may be difficult with an upset child, and it may be difficult to distinguish pain from other causes of distress (fear, stranger anxiety, etc.). Choosing the right words so that you and the child understand each other means listening or asking what words the family uses, e.g. hurt, sore, poorly. In some cases children may deny pain for fear of the ensuing treatment (particularly needles).
There is often insecurity about dosage of medication in children, which has to be worked out in mg/kg. Some medications are not licensed for use in children, although are commonly used. And there are practical issues such as the psychological and real issues of inserting a cannula for intravenous analgesia.
WHAT ARE WE TREATING?
Pain – This requires analgesia (see below).
Fear of the situation – All efforts should be made to provide a calm, friendly environment. You should explain what you are doing, prepare the child for any procedures and let the parents stay with the child unless they prefer not to or are particularly distressed.
Loss of control – Children like to be involved in decisions and feel that they are being listened to.
Fear of the injury – Distraction and other cognitive techniques are extremely useful (see below). A little explanation and reassurance goes a long way to allay anxiety.
Fear of the treatment – Unfortunately, some treatments hurt and are frightening in themselves (e.g. sutures). There are lots of things you can do to make procedures less stressful all round; this is covered below.
ASSESSMENT OF PAIN
Pain assessment and treatment now forms an integral part of quality assurance standards for emergency departments in many countries and features in most triage guidelines.
If there is severe pain, is there a major injury or ischaemia?
Your prior experience of injuries can help in estimating the amount of pain the child is likely to be in. For example a fractured shaft of femur or a burn are more painful than a bump on the head. After that, you will rely on what the child says and how the child behaves.
Clearly, the younger the child, the less they are able to describe how they are feeling, and separating out the distress caused by pain versus distress caused by other factors is tricky. Some children with mild pain can be very upset, due to the stress of the whole situation, the circumstances of the accident, their prior experience of healthcare or because their parents are upset. Having a reassuring environment and staff trained to be comfortable in dealing with distressed children makes a big difference.
Asking a child to rate their pain is difficult; they have little life experience to draw upon and may not clearly remember previous painful episodes, yet we are asking them to make a judgement of whether they are experiencing mild pain or the worst pain they have ever had! Linear analogue scales of 0–10 or comparisons with stairs or a ladder are often too abstract for a child.
Faces scores showing emotions such as those in Table 2.1 are frequently used for self-reporting of pain in children. They have value but cannot be used in isolation, as they can also be flawed. Children may misunderstand the question because a spectrum of pain can be too difficult a concept. They may point to the happy face because that is how they want to feel or choose the saddest face to reflect how sad they feel.
Table 2.1 Pain assessment tool ...
